Is BN 9789514283321

D908etukansi.
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OULU 2007
D 908
D 908
ACTA
UNIVERSITY OF OULU P.O. Box 7500 FI-90014 UNIVERSITY OF OULU FINLAND
ACTA
U N I V E R S I T AT I S O U L U E N S I S
D
A C TA U N I V E R S I TAT I S O U L U E N S I S
S E R I E S E D I T O R S
Miia Metsänen MEDICA
ASCIENTIAE RERUM NATURALIUM

THOUGHT DISORDER AS
Miia Metsänen
Professor Mikko Siponen
BHUMANIORA A PREDICTIVE SIGN OF

MENTAL DISORDER
Professor Harri Mantila
CTECHNICA
Professor Juha Kostamovaara
A STUDY OF HIGH-RISK AND LOW-RISK ADOPTEES
DMEDICA
Professor Olli Vuolteenaho
IN THE FINNISH ADOPTIVE FAMILY STUDY OF
SCHIZOPHRENIA
ESCIENTIAE RERUM SOCIALIUM
Senior Assistant Timo Latomaa
FSCRIPTA ACADEMICA
Communications Officer Elna Stjerna
GOECONOMICA
Senior Lecturer Seppo Eriksson
EDITOR IN CHIEF
EDITORIAL SECRETARY
Publications Editor Kirsti Nurkkala FACULTY OF MEDICINE,
DEPARTMENT OF PSYCHIATRY,
UNIVERSITY OF OULU;
ISBN 978-951-42-8331-4 (Paperback) DEPARTMENT OF PSYCHIATRY,
ISBN 978-951-42-8332-1 (PDF) OULU UNIVERSITY HOSPITAL;
ISSN 0355-3221 (Print) CLINIC OF PSYCHIATRY,
ISSN 1796-2234 (Online) PÄIJÄT-HÄME CENTRAL HOSPITAL
ACTA UNIVERSITATIS OULUENSIS
D Medica 908
MIIA METSÄNEN
THOUGHT DISORDER AS
A PREDICTIVE SIGN OF
MENTAL DISORDER
A study of high-risk and low-risk adoptees in
the Finnish Adoptive Family Study of Schizophrenia
Academic dissertation to be presented, with the assent of

the Faculty of Medicine of the University of Oulu, for
public defence in the Auditorium of the Department of
Pharmacology and Toxicology, on February 9th, 2007, at
12 noon
O U L U N Y L I O P I S TO, O U L U 2 0 0 7
Copyright © 2007
Acta Univ. Oul. D 908, 2007
Supervised by
Docent Karl-Erik Wahlberg
Docent Outi Saarento
Reviewed by
Docent Risto Antikainen
Docent Eila Laukkanen
ISBN 978-951-42-8331-4 (Paperback)

ISBN 978-951-42-8332-1 (PDF)
http://herkules.oulu.fi/isbn9789514283321/
ISSN 0355-3221 (Printed)
ISSN 1796-2234 (Online)
http://herkules.oulu.fi/issn03553221/
Cover design
Raimo Ahonen
OULU UNIVERSITY PRESS

OULU 2007
Metsänen, Miia, Thought disorder as a predictive sign of mental disorder. A study of
high-risk and low-risk adoptees in the Finnish Adoptive Family Study of
Schizophrenia
Faculty of Medicine, Department of Psychiatry, University of Oulu, P.O.Box 5000, FI-90014
University of Oulu, Finland; Department of Psychiatry, Oulu University Hospital, P.O. Box 26, FI-
90029 OYS, Finland; Clinic of Psychiatry, Päijät-Häme Central Hospital, Keskussairaalankatu 7,
FI-15850 Lahti, Finland
Oulu, Finland
Abstract
Early recognition of schizophrenia could lead to a better clinical course and a better prognosis.
Therefore, researchers have started to investigate the possible vulnerability markers of schizophrenia.
Both genetic and environmental factors have been found to be essential in the understanding of the
development of psychiatric disorders.
The present study is part of an extensive Finnish adoptive family study of schizophrenia. The
substudies of this thesis focused on investigating the predictive value of thought disorder measured
by Thought Disorder Index (TDI) in terms of the future psychiatric disorders of adoptees at high risk
(HR, biological mother with a diagnosis of schizophrenia or paranoid psychosis) and low risk (LR,
biological mother with no diagnosed psychosis) for schizophrenia, who had no psychiatric diagnosis
at the initial assessment (n = 171). The adoptees' psychiatric status was first re-assessed based on the
DSM-III-R criteria in a re-interview 11 years later and then based on the available national hospital
discharge registers 16 years later. The predictive value of thought disorder as a sign of vulnerability
to mental disorder was clarified by examining the stability of thought disorder (n = 158). The
adoptees' TDI scores were evaluated twice at a median interval of 12 years (the adoptees' median ages
at evaluation were 22 and 36 years). Furthermore, the possible genotype-environment effect in the
development of thought disorder was investigated by assessing the adoptees' thought disorders at the
initial and follow-up assessments as well as the CD (Communication Deviance) of their adoptive
parents at the initial assessment (n = 89).
High scores on several TDI variables at the initial assessment were shown to predict a follow-up
diagnosis of a psychiatric disorder among all adoptees. These TDI variables were found to be stable
over time, which enhanced the predictive value of thought disorder. There was an association
between the thought disorder of the adoptees and the CD of their parents. Furthermore, the genotype
- environment interactions were also related to the presence of thought disorder.
The results of these investigations provide new information to the prevention of mental disorders,
especially among person with prodromal symptoms of psychosis, such as mood disorders and
cognitive dysfunctions.
Keywords: adoption family study, communication deviance, schizophrenia, thought

disorder
Metsänen, Miia, Ajatushäiriöt mielenterveyden häiriöiden ennustajana. Suomalaisen
adoptiolapsiperheaineiston riski- ja verrokkilapset.
Lääketieteellinen tiedekunta, Psykiatrian klinikka, Oulun yliopisto, PL 5000, 90014 Oulun
yliopisto; Psykiatrian klinikka, Oulun yliopistollinen sairaala, PL 26, 90029 OYS; Psykiatria
klinikka, Päijät-Hämeen keskussairaala, Keskussairaalankatu 7, 15850 Lahti
Oulu
Tiivistelmä
Skitsofrenian varhaisen tunnistamisen myötä saattaa olla mahdollista kohentaa skitsofrenian
ennustetta. Siksi tutkijat selvittävät mahdollisia skitsofreniaan altistavia ja ennakoivia tekijöitä. Sekä
geneettiset että ympäristöstä johtuvat tekijät ovat nousseet olennaisiksi seikoiksi psykiatristen
häiriöiden kehittymisen ymmärtämisessä.
Tämä tutkimus on osa laajempaa Suomalaista adoptiolapsitutkimusta. Tutkimuksen tavoitteena
oli selvittää ennustavatko Thought Disorder Index -asteikolla (TDI) mitatut ajatushäiriöt
tutkimushetkellä oireettomien (eivät täyttäneet psykiatrisen diagnoosin kriteereitä) riski (biologinen
äidillä skitsofrenia tai paranoidinen psykoosi diagnoosi)- ja verrokkiadoptiolasten (biologisella
äidillä ei psykoosi diagnoosia) tulevaa mielenterveyttä (n = 171). Adoptiolasten psykiatrinen status
arvioitiin 11 vuotta myöhemmin tehdyssä seurantatutkimuksessa DSM-III-R -kriteeristöllä ja tämän
jälkeen vielä seuraamalla 16 vuotta kansallisia sairaaloiden uloskirjoitusrekistereitä. Ajatushäiriöiden
ennustearvoa toimia haavoittuvuusindikaattoreina selvitettiin tutkimalla ajatushäiriöiden pysyvyyttä
(n = 158). Adoptiolasten TDI pisteet arvioitiin kahdesti heidän ollessa 22- ja 36-vuotiaita,
tutkimuksen alussa ja 12 vuoden (mediaani) seuranta-ajan jälkeen. Lisäksi mahdollista perimä-
ympäristötekijöiden yhdysvaikutusta ajatushäiriöiden kehittymisessä tutkittiin arvioimalla
adoptiolasten adoptiovanhempien kommunikaatiohäiriöt (CD) alkututkimuksessa ja adoptiolasten
ajatushäiriöt sekä alku- että seurantatutkimuksessa (N = 89).
Eräät alkututkimuksessa mitatut kohonneet TDI-muuttujat (TDR = TDI-astekon
kokonaispistemäärä, 0.50 vakavuusaste ja omituinen sanojen käyttö) ennustivat seurannassa
adoptiolasten psykiatrisen diagnoosin kriteerien täyttymistä. Kyseiset TDI-muuttujat olivat myös
pysyviä ja täten niiden ennustearvo vahvistui. Adoptiolasten ajatushäiriöiden kehittyminen alku- ja
seurantatutkimuksen välillä oli yhteydessä alkututkimuksessa mitattuun adoptiovanhempien
kommunikaatiohäiriöiden esiintyvyyteen ja perimän ja ympäristön yhdysvaikutus tuli esille.
Tämän tutkimuksen tulokset tuovat uutta tietoa ennaltaehkäisevälle mielenterveystyölle,
erityisesti niiden henkilöiden kohdalla, joilla esiintyy joitakin huolestuttavia, erityisesti psykoosin
ennakko-oireita kuten mieliala-oireita ja kognitiivisia muutoksia.
Asiasanat: ajatushäiriö, skitsofrenia, adoptioperhetutkimus, kommunikaatiohäiriöt

Kimmolle ja Aleksille
Acknowledgements
This work was carried out at the Department of Psychiatry, University of Oulu, Clinic of
Psychiatry, Oulu University Hospital, and Clinic of Psychiatry, Päijät-Häme Central
Hospital.
I would like to express my sincere gratitude to Docent Karl-Erik Wahlberg, Ph.D, and
Docent Outi Saarento, M.D., who supervised my research. Both of them gave me
enormous amounts of intellectual supervision and advice during the research project. I
would especially like to thank Docent Karl-Erik Wahlberg for answering to every
question I had (and there were many), for being there every time I had problems, and the
possibility to have supervision via videoconference, thousands of emails, and
innumerable telephone calls. This research would not have been possible without your
flexibility and humanity.
I owe my deep gratitude to Emeritus Professor Pekka Tienari. His enormous
contribution to the Finnish Adoptive Family Study of Schizophrenia has created a unique
sample, and has offered an opportunity to conduct several studies. Furthermore, Emeritus
Professor Pekka Tienari gave me valuable advice and was always willing to help
whenever I needed guidance. I thank the psychologists Taneli Tarvainen, Lic. Psych.,
Pekka Koistinen, Ph.D., and Karl-Erik Wahlberg, Ph.D., for teaching me the scoring of
Rorschach records. For statistical advice I am grateful to Jouko Miettunen, Ph.D., and
Helinä Hakko, Ph.D. I thank especially Helinä Hakko for being extremely helpful and
supportive about every issue I had.
My sincere thanks are also due to Professor Matti Joukamaa and Professor Ranan
Rimon for supporting me in many financial issues. I wish to express my profound
gratitude to Ms. Pirkko Kaan for helping me in many practical questions and to Mrs.
Sirkka-Liisa Leinonen, who revised the language of the manuscript and the published
articles.
I would also like to express my sincere gratitude to all those people, who have made
huge contributions to the Finnish Adoptive Study of Schizophrenia in data collection and
analysis: Heljä Anias-Tanner, M.A., Pirjo Keskitalo, Ph.D., Ilpo Lahti, M.D., Ph.D.,
Kristian Läksy, M.D., Mikko Naarala, M.D., Docent Juha Moring, M.D., Ph.D., Outi
Saarento, M.D., Markku Seitamaa, M.A. and Anneli Sorri, M.D.
Docent Risto Antikainen, Ph.D., and Docent Eila Laukkanen, M.D., carefully
reviewed the manuscript and gave valuable advice and constructive criticism, for which I
extend my warmest thanks.
While I was working at Visala Psychiatric Hospital in the Northern Ostrobothnia
Hospital District, I had an opportunity to participate in the Finnish Adoptive Family
Study of Schizophrenia. Without the extremely favourable attitude of Kari Lehtinen,
Chief Medical Officer and Pentti Ollanketo, Director of Nursing Service, at Visala
Psychiatric Hospital, this research project would not have succeeded. Therefore, I am
deeply grateful for their support. I am also grateful to my nearest co-workers in Päijät-
Häme Central Hospital and to my bosses Per-Erik Bredbacka, Eija Kivinen and Auli
Sarikka for the time they have allowed me to pursue my research. The warmest thanks go
to my closest co-worker Jaana Hahl-Viljanen. You have supported me on good and bad
days.
Financial support for this research was obtained from the grant MH39663 from the
Public Health Service, a grant from the Scottish Rite Schizophrenia Research Program,
N.M.J., USA, and from The Academy of Finland, The Emil Aaltonen Foundation, The
Finnish Konkordia-Union, The Jalmari and Rauha Ahokas Foundation, Yrjö Jahnsson
Foundation, The Paolo Foundation, Päijät-Häme Central Hospital, Oulu University
Hospital, Department of Psychiatry, The Alma and K.A. Snellman Foundation and
Varhaiskuntoutuksen tukisäätiö.
My deepest thanks are due to my husband Kimmo and my three-year-old son Aleksi.
Words are not enough to express my gratitude for the support you gave me during these
years. Kimmo, you taught me that it is possible to take things easy and rationally. Aleksi,
your calm and easy temperament made it possible for your mother to have the strength to
work on research during your naps. During your first two years you participated in many
scientific meeting while asleep, and hopefully this has not stifled your interest in science
in the future. To my parents, thank you for having been my parents. Your attitude to life
has shown that everything is possible if you just want it. This book is my birthday present
to my mother on the 9th of February 2007.
Kangasala 7.12.2006 Miia Metsänen
Abbreviations
ANCOVA Analysis of covariance
APD Any Psychiatric Disorder
AOPD Any Other Psychiatric Disorder
BSSD Broad Schizophrenia Spectrum Disorder
CD Communication Deviance
DSM-III-R Diagnostic and Statistical Manual of Mental Disorders, Third Edition,
Revised
HR High-risk adoptee
LR Low-risk adoptee
NPD No Psychiatric Disorder
OR Odds Ratios
TDI Thought Disorder Index
TDR Thought Disorder on the Rorschach
List of original publications
This thesis is based on the following original publications, which are referred to in the
text by the Roman numerals I-IV.
I Metsänen M, Wahlberg K-E, Saarento O, Tarvainen T, Miettunen J, Koistinen P,
Läksy K & Tienari P (2004) Early Presence of Thought Disorder as a Prospective
sign of Mental Disorder. Psych Res 125:193-203.
II Metsänen M, Wahlberg K-E, Saarento O, Hakko H, Tarvainen T, Koistinen P &
Tienari P (2005) Stability of Thougth Disorder Index among high-risk and low-risk
adoptees in Finnish adoptive family study of schizophrenia. Eur Psych 20:35-40.
III Metsänen M, Wahlberg K-E, Hakko H, Saarento O & Tienari P (2006) Thought
Disorder Index. A longitudinal study of severity levels and schizophrenia factors. J
Psych Res 40:258-266.
IV Metsänen M, Wahlberg K-E, Hakko H, Saarento O, Tarvainen T, Koistinen P, Tienari
P (2006) Longitudinal association between thought disorder of adoptees and
Communication Deviance of their adoptive parents. Manuscript.
Contents
Abstract
Tiivistelmä
Acknowledgements
Abbreviations
List of original publications
Contents
1 Introduction ................................................................................................................... 17
2 Review of the literature ................................................................................................. 19
2.1 General systems theory, biopsychosocial model and vulnerability theories..........19
2.2 Thought disorder.....................................................................................................20
2.2.1 Definition of thought disorder .......................................................................20
2.2.2 Cognitive mechanisms in thought disorder ...................................................21
2.2.3 The qualitative aspects of thought disorder ...................................................21
2.2.4 Thought disorder in psychiatric disorders .....................................................22
2.2.5 Stability of thought disorder ..........................................................................24
2.2.6 Assessment of thought disorder.....................................................................25
2.3 Communication deviance .......................................................................................25
2.3.1 Communication patterns in the development of thought processes...............25
2.3.2 The Definition of Communication Deviance.................................................26
2.3.3 Parental Communication Deviance and the psychiatric status of the
offspring ......................................................................................................27
2.3.4 Stability of Communication Deviance...........................................................27
2.3.5 Connection between parental Communication Deviance and the
psychiatric disorder in the offspring............................................................28
2.4 Summary of the literature reviewed .......................................................................28
3 Aims of the present study .............................................................................................. 30
4 Materials and methods................................................................................................... 31
4.1 Study population of the Finnish Adoptive Family Study of Schizophrenia...........31
4.2 Procedure of the study ............................................................................................32
4.3 Study samples in the original publications I-IV .....................................................32
4.4 Variables .................................................................................................................34
4.4.1 Thought Disorder Index (I-IV) ......................................................................35
4.4.2 The validity and reliability of TDI.................................................................36
4.4.3 Communication Deviance (IV) .....................................................................37
4.4.4 DSM-III-R diagnoses of the adoptees (I-IV).................................................39
4.5 Statistical methods..................................................................................................40
4.6 Ethical considerations.............................................................................................40
4.7 Personal involvement .............................................................................................41
5 Results ........................................................................................................................... 42
5.1 Premorbid signs of thought disorder and psychiatric disorder at follow-up
(I)...........................................................................................................................42
5.2 Stability of thought disorder (II, III).......................................................................44
5.3 Association between parental Communication Deviance (CD) and
adoptee’s thought disorder (IV).............................................................................47
6 Discussion ..................................................................................................................... 49
6.1 Discussion of the results (I-IV)...............................................................................49
6.1.1 Thought disorder as a prospective sign of mental disorder (I) ......................49
6.1.2 Stability of thought disorder (II, III)..............................................................50
6.1.3 Parental communication deviance and thought disorders of
offspring (IV) ..............................................................................................51
6.2 Strengths and limitations of the studies (I-IV)........................................................52
7 Conclusions ................................................................................................................... 53
7.1 Main results ............................................................................................................53
7.2 Clinical implications and implications for future research .....................................53
References
Appendix
Original publications
1 Introduction
The course and prognosis of schizophrenia could be improved by recognition of the
disorder as early as possible (McGlashan & Johannessen 1996, McGorry et al. 2000).
Therefore, there is an apparent need to explore the possible vulnerability markers of
schizophrenia. Previous studies have focused on anatomical, molecular, physiological,
chemical, and other biological abnormalities as signs of vulnerability to schizophrenia
(Carpenter & Buchanan 1994). It is also obvious that genetic factors play an important
role in the development of schizophrenia.
According to the vulnerability/stress and stress-diathesis models, there are inherited
and possible neural factors that make some persons more vulnerable to developing
symptoms of schizophrenia in stressful life situations (Rosenthal 1963, Zubin & Spring
1977, Nuechterlein 1987). Cognitive deficits have been found to be characteristic of
schizophrenia as well as essential vulnerability signs of the disorder. The cognitive
functioning of schizophrenic patients has been shown to be 1-1.75 standard deviations
below the normal mean (Censits et al. 1997, Heaton et al. 2001, Mohamed et al. 1999).
The meta-analytic study of Heinrichs & Zakzanis (1998) revealed that almost all aspects
of cognition are somewhat impaired in schizophrenia, especially episodic memory,
ideational fluency, and aspects of complex attention. Furthermore, these cognitive deficits
appear to be relatively stable over time and independent of symptomatic manifestations
of the illness (Censits et al. 1997, Heaton et al. 2001, Rund 1998). Several studies have
further revealed impairments in intellectual, attentional, and academic functioning in
early childhood, which are likely to increase the risk of subsequent psychotic symptoms
(Cannon et al. 2000, Cornblatt et al. 1999, David et al. 1997, Davidson et al. 1999,
Erlenmeyer-Kimling et al. 2000, Erlenmeyer-Kimling et al. 2001, Isohanni et al. 2000,
Jones et al. 1994, Niendam et al. 2003). Cannon et al. (2000) found cognitive
dysfunction to be evident as long as 10-15 years before the onset of formal diagnostic
symptoms. Furthermore, Erlenmeyer-Kimling et al. (2000) pointed out that subjects who
experienced schizophrenia-related psychoses in adulthood had deficits in verbal memory,
gross motor skills, and attention at 7-12 years of age already. Among cognitive
impairments, thought disorders have been related to mental disorders, especially
schizophrenia. Therefore, attention has been given to the possibility that the presence of
thought disorder could be an indicator of vulnerability to schizophrenia (Hurt et al. 1983,
18
Arboleda & Holzman 1985, Nuechterlein et al. 1986, Koistinen 1995, Wahlberg et al.
1997, 2000, Ott et al. 2001). Ott et al. (2002) were able to show that global, negative, and
positive thought disorders were present in subjects (n=123) with adult schizophrenia at
age 9 already, i.e. years before onset of psychosis.
At the same time, environmental factors, such as complications of delivery (McNeil
1991, Cannon et al. 1993, Jones et al. 1998, Isohanni et al. 2004) and viral infections of
the mother in the second trimester (Sorensen et al. 2004, Tochigi et al. 2004), have been
found to be risk factors for schizophrenia. Unwanted pregnancy (Myhrman et al.1996)
and maternal depression during the antenatal period (Jones et al. 1998) have also been
associated with the development of schizophrenia. In contrast to the differentiation
between genetic and environmental factors, Kendler & Eaves (1986) pointed out that
comprehensive understanding of the development of psychiatric disorders presumes
recognition of the joint effect of genetic and environmental risk factors. Today, it is
widely accepted that genotype-environment interaction is essential for the development
of schizophrenia (Carter et al. 2002, Tienari et al. 2004, Wahlberg et al. 2004).
One possible environmental risk factor is the communication deviance (CD) present in
these families (Wynne et al. 1977). Adoptees at high genetic risk for schizophrenia have
been found to be more sensitive to problems in the rearing adoptive family (Tienari et al.
2004). Correspondingly, the interaction of genetic liability to schizophrenia spectrum
disorder and communication deviance of the adoptive parents have predicted psychiatric
disorders in the adoptees at adult age (Wahlberg et al. 2004). Wahlberg et al. (1997,
2000) also demonstrated that thought disorder differentiated high-risk adoptees from low-
risk adoptees only in the presence of high levels of communication deviance. Therefore,
the adoptees at high genetic risk could be more sensitive to the environment, including a
protective environment. High-risk adoptees with low communication deviance adoptive
parents had more consistent thought processes than low-risk adoptees reared by parents
with low communication deviance levels (Wahlberg et al. 1997).
This study is part of the Finnish adoptive family study (Tienari et al. 1987a,b, 2000,
2003), which aims to explain the relationships between the genetic and environmental
factors contributing to the normal and psychopathological outcomes of subjects at genetic
risk. The adoptive study design provides an opportunity to differentiate between family
rearing variables and genetic risk. The purpose of the present study was to explore
vulnerability markers among individuals at risk to get a psychiatric diagnosis in the
future. A further aim was to investigate variables that could be associated with the
development of vulnerability markers.
2 Review of the literature
2.1 General systems theory, biopsychosocial model

and vulnerability theories
Comprehensive understanding of human development and the development of psychiatric

disorders requires a broad perspective. The general systems theory (Bertalanffy 1969,
Benjamin 1982) and the biopsychosocial model (Engel 1977) connect the neurobiological
factors, the individual development, and the broad environmental influence. From the
systematic perspective, a phenomenon is considered a whole of several parts, which are
in reciprocal interaction (Bertalanffy 1969, Benjamin 1982). A change in one part of the
system changes the whole system, and the feedback influences the part that initiated the
change in the first place. The system has a tendency towards homeostasis, meaning that it
resists the change with negative feedback. However, the system is able to change and
develop with the help of positive feedback.
The biopsychosocial model includes four major levels which influence human
behavior (Engel 1977). These are the biological level, the personality, the social network,
such as family and work, and the larger community and the state. From the systematic
viewpoint, a change at one of these four levels affects the other levels as well.
In studies of psychiatric disorders, especially schizophrenia, the vulnerability/stress
and diathesis-stress theories have offered a broad perspective, which draws on the general
systems theory and takes into account both genetic, individual, and environmental factors
in the development of psychiatric disorder (Rosenthal 1963, Zubin & Spring 1977,
Wynne 1978, Nuechterlein & Dawson 1984, Nuechterlein 1987). The core idea in these
theories is that there is a vulnerability to schizophrenia, in which both biological factors
(derived from genetic or environmental causes) and life experience factors play a role
(Mirsky & Duncan 1986). Stress activates this diathesis, and the potential predisposition
(vulnerability) transforms into the presence of psychopathology (Monroe & Simons
1991). Vulnerability factors are non-specific, internal, and inherited dimensions, which
are mostly related to the development of genetic and neural factors (Wynne 1978, Green
1998). In addition, complications during pregnancy and delivery may influence the
development of the central nervous system (Nuechterlein 1987). Environmental stressors
20
include communication deviance in the family. Green (1998) has speculated that the
greater the vulnerability is, the less pressure in the environment is needed for the onset of
a psychiatric disorder. Vulnerability models have also revealed protective factors.
Nuechterlein (1987) has proposed that a personal ability of adjustment and good
communication and problem-solving skills in the family could protect from psychiatric
disorder.
2.2 Thought disorder
2.2.1 Definition of thought disorder
Thought disorder has been a familiar term in psychiatry ever since Emil Kraepelin
(1896/1919) and Eugen Bleuler (1911/1950, 1924) identified thinking problems as one of
the primary features of schizophrenia. However, psychiatric researchers have not reached
full consensus as to the definition of thought disorder. Kraepelin (1896/1919) identified
the incoherence and “derailments” of thought sequences in schizophrenia, while Bleuler
(1911/1950) emphasized the splitting of thoughts and feelings and called this process
“loosening of associations”. Other early theorists, such as Storch (1924) and Werner
(1957), believed primitive language usage to be characteristic of schizophrenic patients.
Correspondingly, Goldstein (1944) and Arieti (1974) viewed schizophrenic thinking on
the concrete-abstract continuum. Goldstein (1944), Arieti (1974), and Barison (1949)
characterized thought processes in schizophrenia as concrete, while Barison (1949) found
schizophrenic thinking to be overly abstract. Cameron (1944) considered the thinking
problems in schizophrenia to be due to an inability to maintain conceptual boundaries, in
accordance with Fish (1962), who defined thought disorder as a disturbance of
conceptual thinking. Von Domarus (1944) added to the conceptualization of thought
disorder the idea of predicative thinking, which means that two things are identified on
the basis of a common predicate rather than on the basis of a common subject. Some
psychoanalytically orientated scholars viewed schizophrenic thinking as the
manifestation of the primary process, representing a regression to an earlier, infantile
state of psychic development (Johnston & Holzman 1979), while Harrow and Quinlan
(1985) regarded thought disorder as consisting of diverse types of verbalization and
thinking labeled by others as bizarre and idiosyncratic. Today, thought disorder is
considered a broader phenomenon, including not only impaired pace and flow of
associations, but also errors in syntax, word usage, syllogistic reasoning, inappropriate
levels of abstracting, failure to maintain conceptual boundaries, and breakdown of the
discrimination of internal from external perceptions (Kleiger 1999).
21
2.2.2 Cognitive mechanisms in thought disorder
Although psychiatric researchers have not reached agreement concerning the definition of
thought disorder, it is widely accepted that language and speech provide the structure
through which thought is communicated (Harrow & Quinlan 1985, Lanin-Kettering &
Harrow 1985, Holzman et al. 1986). Numerous studies have investigated the cognitive
and neurological substrate of thought disorder. Impairments in attention, information
processing, working memory, discourse planning, and semantic processing have been
found to be related to thought disorders in schizophrenia (Nuechterlein & Dawson 1984,
Hoffman et al. 1986, Liddle 1987, Manschreck et al. 1991, Shenton et al. 1992, Goldberg
et al. 1998, Nestor et al. 1998, Tallent et al. 2001, Minassian et al. 2004, Leeson et al.
2005). It has been suggested that, because of a deficit in working memory, schizophrenic
patients lose their train of thought, fail to perceive causal relationships, and are unable to
regulate their behavior by internal schemata and ideas (Goldman-Rakic 1992).
Impairments in different aspects of executive function have also turned out to be related
to thought disorder (McGrath 1991, Goldstein et al. 2002, Kerns & Berenbaum 2003,
Dixon et al. 2004, Covington et al. 2005). For example, poor planning could make an
individual unable to focus on a topic and thereby give rise to a loss of goal.
Studies concerning the pathophysiology of thought disorder have concluded that there
are multiple brain areas and/or miscommunication between brain areas producing
disturbed thinking (Friston 1998, Andreasen et al. 1999). Studies of brain morphology
have found that, especially among schizophrenic patients, the degree of reduced or
reversed lateralization of the posterior superior temporal gyrus is associated with the
severity of thought disorder (Shenton et al. 1992, Rossi et al. 1994, Petty et al. 1995,
Hirayasu et al. 1998, Rajarethinam et al. 2000, Kircher et al. 2002). High degrees of
thought disorder have also been accompanied by significant activations in the fusiform
gyrus and precuneus (Erkwoh et al. 2002). Kircher et al. (2001) further found the severity
of positive thought disorder to correlate inversely with the level of activity in the
Wernicke area.
In summary, previous studies concerning the cognitive background of thought disorder
have produced different results on what is essential in thought disorder. However, the
evaluation of these studies is quite challenging because of their marked diversity.
Different studies have used different methods, and sample sizes have not always been
very large. It could be presumed that, especially in studies of pathophysiology,
technological development could offer more sophisticated methods in the future and thus
enable more precise results.
2.2.3 The qualitative aspects of thought disorder
Schizophrenia research has made a general distinction between positive and negative
symptoms. This differentiation has also been applied to thought disorder. Positive thought
disorder includes unusual ideas, delusions, and hallucinations and is commonly flagrantly
apparent as bizarreness of speech and logic (Kleiger 1999). Thinking affected by positive
thought disorder is not based on normal logic (Marengo & Harrow 1988).
22
Correspondingly, negative thought disorder is considered a deficit or absence of normal
functioning, such as poverty of speech and thought content (Kleiger 1999). Persons with
negative thought disorder have special difficulty in producing thoughts (Marengo &
Harrow 1988).
Extensive research made it apparent that thought disorder is not a single phenomenon
but consists of several factors. Harrow and Quinlan (1985) showed different types of
thought disorder to be present in the different phases of a psychiatric disorder. Looseness,
conceptual overinclusiveness, and fallacious logic were more often present in acute
conditions, while inability to think abstractly and excessively concrete thinking were
more prominent among chronic schizophrenic patients (Harrow & Quinlan 1985).
Johnston & Holzman (1979) found concept formation, cognitive focusing, reasoning, and
reality testing to be important components of thought disorder.
Thought disorder has turned out to be a continuous variable. Disordered thinking
appears to vary between milder forms of thought disorder and more severe thinking
problems (Harrow & Quinlan 1977, 1985; Johnston & Holzman 1979, Andreasen &
Grove 1986, Holzman et al. 1986). There is also variability within a given diagnostic
group or even within an individual, depending on the phase of the illness (Harrow &
Quinlan 1977). Positive and negative thought disorders have also been seen within one
and the same person (Pogue-Geile & Harrow 1985).
Although previous studies have used different methods to evaluate thought disorder,
their results have consistently shown that thought disorder consists of several factors and
is a continuous variable. Furthermore, the samples have included dozens of subjects in
each psychiatric disorder group.
2.2.4 Thought disorder in psychiatric disorders
Thought disorder has been traditionally associated with schizophrenia. The thinking and
speech of schizophrenic patients seem to be confused and disorganized and contain
idiosyncratic and peculiar phrases (Johnston & Holzman 1979, Holzman et al. 1986,
Solovay et al. 1987, Koistinen 1995). Furthermore, fluid and perseverative responses,
which seem odd and devoid of consensual meaning to the listener, have been shown to be
typical of schizophrenia (Kleiger 1999). Extremely severe thought disorders, such as
neologisms, incoherent statements, and responses merging two separate and incompatible
percepts (contamination), have been found among schizophrenic patients (Harrow &
Quinlan 1985, Koistinen 1995). The thinking of schizophrenic and schizotypal children is
also more impaired than that of normal children (Caplan et al. 1989, 1990, 2000; Caplan
1994, Tompson et al. 1997). Especially illogical thinking and loose associations were
more characteristic of schizophrenic and schizotypal children (Caplan et al. 1989, 1990).
In addition, Caplan et al. (1992) found that schizophrenic children used significantly
fewer cohesive devices to connect ideas expressed within and across sentences than
normal children. Furthermore, Makowski et al. (1997) demonstrated idiosyncratic word
usage, illogical reasoning, perceptual confusion, loss of realistic attunement to the task,
and loosely related ideas among schizophrenic adolescents. Furthermore, Docherty et al.
(2003) indicated clinically rated thought disorder to be associated with the severity of
23
positive but not negative schizophrenic symptoms. The level of thought disorder has also
been found to be significantly elevated in the relatives of persons with schizophrenia
(Johnston & Holzman 1979, Shenton et al. 1989, Hain et al. 1995, Vaever et al. 2005).
The thought processes of the first-degree relatives of schizophrenic and schizoaffective
manic patients have also been shown to be more deviant than those of normal controls
(Shenton et al. 1989, Kinney et al. 1997). In view of the large number of studies with
sample sizes ranging from 20 to 88 inpatients and outpatients with chronic and recent
schizophrenis as well schizophrenic and schizotypal children, the presence of thought
disorder in schizophrenia is convincing.
Thought disorder is present in other psychiatric disorders as well. Previous studies
have shown thought disorder in patients with obsessive-compulsive (n=15) (Lee et al.
2005), affective (n=1-48) (Dunayevich & Keck 2000, Wilcox 2000, Rubin & Arceneauz
2001, Dixon et al. 2004, Tai et al. 2004), schizoid (n=32) (Wolff et al. 1991), and
borderline personality disorders (n=51-83) (Edell 1987, Gandolfo et al. 1991).
Furthermore, thought disturbances have been found in schizotypal disorder (n=50)
(Handest & Parnas 2005) as well as in autistic (n=11-14) (Dykens et al. 1991, van deer
Gaag et al. 2005), bulimic (n=12) (Smith et al. 1991), and multiple complex
developmental disorders (n=20) (van deer Gaag et al. 2005) and in children with
attention-deficit hyperactivity disorder (ADHD) (n=13-115) (Caplan et al. 2001, van deer
Gaag et al. 2005). However, studies have revealed qualitative differences in thought
disorder, depending upon the severity of the psychopathology (Holzman et al. 1986,
Cuesta & Peralta 1993, Vaever et al. 2005). Holzman et al. (1986) showed that manic
patients (n=20) produce more often combinatory thinking, intrusions of irrelevant ideas,
and playful and humorous statements. Correspondingly, the thinking of schizophrenic
patients (n=43) involved interpenetrations of one idea into another and idiosyncratic and
peculiar words. Thought disorders among schizoaffective (n=22) and schizophrenic
patients (n=43) have been found to include many similarities and congruence (Shenton et
al. 1987). Similarly to schizophrenia, idiosyncratic verbalizations, autistic thinking, and
confusion were also present in the thinking of schizoaffective-manic patients. The
number of studies concerning thought disorder in psychiatric disorders other than
schizophrenia is large, and the sample sizes are sufficient to warrant the conclusion that
thought disorder is not unique to schizophrenia.
Although thought disorder is usually related to psychiatric disorders, it is important to
remember that the occurrence of minor cognitive slippage is possible in healthy
individuals as well. Most often, such slippage occurs during periods of anxiety or fatigue
(Solovay et al. 1987). Previous studies have shown that normal subjects (n=22) also have
thought disorders, but they are significantly less common and less severe than those seen
among psychiatric samples (Holzman et al. 1986, Solovay et al. 1987). However, it still
unknown how common thought disorders are in the normal population.
24
2.2.5 Stability of thought disorder
Thought disorder occurs most often during the acute phase of schizophrenia (Asarnow &
MacCrimmon 1982, Harrow et al. 1982, Marengo & Harrow 1997). Some patients
continue to have thought disorder after the acute phase, while improvements in specific
areas of thought disorder occur. Overall, thought disorders have been found to be rather
stable among schizophrenic patients (Adair & Wagner 1992, Earle-Boyer et al. 1986,
Marengo & Harrow 1988). Marengo & Harrow (1997) studied thought disorder in
schizophrenia, schizoaffective disorder, and other psychotic and non-psychotic disorders
at 2, 4.5, and 7.5 years after index hospitalization and found the stability of thought
disorder to be most prominent in schizophrenia (correlations of 0.42-0.47, depending on
the length of follow-up). In other psychiatric disorders, contrariwise, stability was quite
low and thought disorders did not persist throughout the follow-up period. Adair &
Wagner (1992) also found that the group mean of unusual verbalization (UV) scores
among schizophrenic patients did not significantly change during 6.4 years of follow-up.
The correlations were, however, modest at best (r= 0.16-0.50). Negative thought disorder
turned out to be relatively consistent in schizophrenics after 10 days’ acute admission, but
less consistent in manic patients (Earle-Boyer et al. 1986). Docherty et al. (2003) also
found moderate (r=0.48) consistency of formal thought disorder during 9-month follow-
up of schizophrenic patients. Correspondingly, Andreasen & Grove (1986) showed that
most types of thought disorder remitted in manic patients during 6 months of follow-up,
but persisted in schizophrenics, while patients with schizoaffective disorder also showed
substantial improvement of thought disorder.
It appears that thought disorder is a trait in some subgroups of schizophrenic and
manic patients (Braff et al. 1988, Harvey et al. 1990). The presence of thought disorder
after the resolution of an acute psychotic episode appears to be a powerful predictor of
poor outcome (Norman et al. 1999). However, it is also suggested that thought disorder in
psychiatric patients could have both trait and state features (depending on the context)
(Holzman 1986, Ragin & Oltmanns 1986). In healthy individuals, the presence of thought
disorder is assumed to be more a state-like feature. However, some “thinking problem”
subscales measuring communication deviance (CD) have shown certain stability among
adult subjects (r=0.29-0.35) but not among subjects aged 20 years or younger (Wahlberg
et al. 2001). As stated before, the presence of thought disorder could be a sign of
vulnerability to schizophrenia. Furthermore, previous studies have indicated that patients
with thought disorder had a poorer outcome in the future (Harrow et al. 1983, Jorgensen
& Aagaard 1988).
In summary, thought disorder has been found to have both trait and state-like features.
It is noticeable that the stability of thought disorder has not been a very popular topic of
research. Only a few studies have been made, and the follow-up times have not been very
long.
25
2.2.6 Assessment of thought disorder
Thought disorder can be assessed by using interviews (structured or semi-structured) or

different psychological tests. Well-known interviews have included, for example, the
Brief Psychiatric Rating Scale (BPRS) (Overall & Gorham 1962, Andreasen et al. 1974,
Dingemans et al. 1983, Simpson & Davies 1985), the Present State Examination (PSE)
(Ianzito et al. 1974), and the Positive and Negative Syndrome Scale (PANSS) (Kay et al.
1987). In the assessment of thought disorder using psychological tests, the most common
method has been the analysis of responses to Rorschach cards. Several test measures have
been developed to evaluate thought disorder, such as Exner’s Comprehensive System
(Exner 1993), the Scale for the Assessment of Thought, Language and Communication
(TLC) (Andreasen 1986), and the most widely used test, namely the Thought Disorder
Index (TDI) (Johnston & Holzman 1979, Holzman et al. 1986, Solovay et al. 1986).
The Thought Disorder Index (TDI) was developed to tag, classify, and measure
disturbances in thinking (Johnston & Holzman 1979, Holzman et al. 1986, Solovay et al.
1986). TDI can be used to evaluate thinking problems that occur during verbal discourse.
Any verbal sample can be used, but responses to Rorschach cards are most common. TDI
allows assessment of both qualitative and quantitative disturbances of thought processes
ranging from very mild to very severe (Holzman et al. 1986).
2.3 Communication deviance
2.3.1 Communication patterns in the development of thought processes
In general, cognitive development is attributed to both heritable (genetic) and early

environmental factors (Schaie & Zuo 2001, Schaie 2005. Traditionally, it is also
suggested that the stage of intellectual development is reached by age 13 or 16 (Schaie
2005). However, it is very important also to recognize other behavioral developments
such as the adoption or neglect of favorable lifestyles as well as the development of
flexible response styles and appropriate management of stress and emotional conflicts,
that could affect the development of cognitive functions later in life (Rowe & Kahn
1987). Environmental influences do not cease in adulthood (Schaie 2005). The Seattle
Longitudinal Study (n=499, 14 year of follow-up) (SLS; Schaie 1996, Schaie 2005)
showed that, from the age of 25 to 81, cognitive abilities such as inductive reasoning,
verbal memory, perceptual speed, and spatial orientation performance declined evenly
(Schaie et al. 2004). However, the ability to understand ideas expressed in words (verbal
ability) and the ability to understand numerical relationships (numeric ability) showed a
positive age effect such that performance was better at age 46 than 25 (Schaie et al.
2004).
The development of thinking has been found to progress by stages. Piaget (1988)
stated that thinking develops in children in the same order but at individual rates.
Thinking processes change qualitatively upon entry into each new stage. In line with
Piaget, Vygotski (1982) also found the development of thinking to proceed through
26
stages. From the primitive state thinking progressed via different stages to the extremely
logical system. The systematic view of thinking postulates that thought processes develop
in the interaction between the subject and the environment (Bronfenbrenner 1988, 1991a,
1991b). Thus, the development of a child’s thinking is an outcome of the interaction
between the child and the parental communication. The association between the child’s
thinking and the parental communication patterns was first empirically studied by Wynne
& Singer (n= 35 families, of which 20 included young adult schizophrenic offspring, nine
borderline schizophrenic offspring, and six severely neurotic young adult offspring)
(Wynne & Singer 1963a, b; Singer & Wynne 1965a, b). The parents’ ability to share
attention and meaning was regarded as essential to the development of the child’s
thinking. Disorders in parental attention and focusing were seen to have a negative
impact on the emotional and cognitive development of the offspring (Singer & Wynne
1965a). Such disorders in communication patterns create a confusing and disorganized
environment. Topics change all the time, items are not processed to the end, and the child
is not able to learn how to concentrate on the essentials (Wynne & Singer 1963a). The
parents talk either very much or very little, and their speech is difficult to follow and
understand. The ways in which the parents communicate and share attention and meaning
with the child are critical to the child’s cognitive development, especially thinking,
experiencing, and communicating (Stierlin 1969; Wynne & Singer 1963a; Wynne 1968).
Especially the effects of unclear, amorphous, or fragmented communication were found
to be quite destructive for a child with a biological predisposition to schizophrenia
(Singer et al. 1978).
2.3.2 The Definition of Communication Deviance
The concept of communication deviance (CD) was outlined by Wynne and Singer
(Wynne & Singer 1963a, b; Singer & Wynne 1965a, b). CD was defined as an unusual
way of perceiving, talking about, and reasoning about the world. The presence of CD
leaves the listener uncertain, puzzled, and unable to share a focus of attention with the
speaker. Parental CD is a relatively stable (Wahlberg et al. 2001) and enduring
“environmental” stressor during the child’s development.
CD has been found to be a heterogeneous phenomenon involving both perceptual-
cognitive disturbance and disturbance of linguistic-verbal reasoning (Miklowitz &
Stackman 1992). Wynne & Singer (1963a, b) differentiated between fragmented thinking
(difficulties in attention and perception, inadequate integration of stimuli or concepts) and
amorphous thinking (vague, indefinite, perseverative, impoverished speech).
Correspondingly, Jones (1977) found factors related to primarily perceptual
distortion,and factors measuring language or speech deviance. Studies have also proposed
that the perceptual-cognitive part of CD might be largely genetically acquired (Asarnow
et al. 1988, Nuechterlein et al. 1989, Wagener et al. 1986), whereas the forms of CD
reflecting deviance in linguistic-verbal reasoning tend to be more heavily influenced by
psychosocial factors (Miklowitz & Stackman 1992).
27
2.3.3 Parental Communication Deviance and the psychiatric

status of the offspring
Parental communication patterns have been studied in psychiatric patients’ families.

Singer & Wynne (1963) found that the parents of schizophrenics (n=20) produce
significantly more communication deviance than the parents of autistic, acting-out, and
withdrawn children (n=20). Furthermore, Wynne et al. (1977) showed that the total
parental CD scores increased monotonically with the severity of disturbance in the
offspring (normal,n=20; neurotic, n=25; borderline, n=25, and schizophrenic, n=44). It is
noteworthy that, using parental communication data, Singer & Wynne (1965a, b) were
able to predict the offspring diagnosis in 80% of the cases, including the severity of
offspring disturbance and the severity of offspring thinking problems. Parental CD scores
were also related to the child’s poor social adjustment and cognitive performance (n=62)
(Doane et al. 1982). Thus, communication deviance is not unique to the parents of
schizophrenics (Jones et al. 1977, n=44; Velligan et al. 1988, n=54, Miklowitz et al.
1991, n=64, Asarnow et al. 1988). In addition, the studies showed that not all parents of
schizophrenics produce very much communication deviance. It was found that the
parents of children with prevalent thought disorder show a high rate of CD (Sass et al.
1984, n=25; Rund 1986, n=50; Wahlberg 1994, n=154, Wahlberg et al. 1997, n=154).
Thus, parental communication deviance is assumed to be a continuous and long-term
environmental factor affecting the child’s cognitive development (Wahlberg et al. 2000,
n=151).
Parental Communication Deviance has been found in different psychiatric patients’
families, especially in families with severe mental disorder in the offspring. The sample
sizes in these studies have been large enough to provide relevant results. More
importantly, the connection between parental CD and the child’s cognitive development
has been confirmed by adoptive family studies where genetic liability and environment al
effects (CD of the adoptive parents) have been studied both separately and in interaction.
2.3.4 Stability of Communication Deviance
Previous studies have shown Communication Deviance (CD) to have stable, trait-like
features. Doane & Mintz (1987) examined 29 schizophrenic patients and found at 15-year
follow-up that CD was relatively stable among 16 women (r= .59, p<.05). Velligan et al.
(1995) studied Interactional Communication Deviance (ICD) in a series of 24 male
schizophrenic patients and their mothers. The stability of total ICD was .64 for the male
patients and .55 for the mothers over a mean time interval of 88.8 days. Nugter et al.
(1997) investigated the stability of CD and the effect of treatments on 37 two-parent and
14 single-parent families of schizophrenic patients. Parental CD was resistant to change
over a 12-month period in both treatment groups (individual treatment group and
individual treatment plus family therapy). Wahlberg et al. (2001) also found CD to be
stable in the older (over 20 years of age) 158 participants over the 11-year interval,
Furthermore, gender, genetic risk for schizophrenia, and DSM-III-R psychiatric
28
diagnoses had no effect on this stability. The stability of CD has also been verified by
Keskitalo (2000). CD was fairly stable both temporally and from one interactive situation
to another.
2.3.5 Connection between parental Communication Deviance and the

psychiatric disorder in the offspring
The connection between parental CD and psychopathology in the offspring is obvious,

several models have been applied to interpret this correlation. One model presents that
parental CD has a stressful impact on the cognitive development of the offspring, which
results in vulnerabilities of perception, attention, and logical thought (Wynne & Singer
1963a, Jones 1977). According to another model, the parents’ communication deviance is
a reaction to the disordered thinking of the offspring. Referring to this model, Bell (1968)
stated that the strange and incomprehensible behavior of a schizophrenic child provokes
strange behavior in the parents. Correspondingly, the third model postulates that
perceptual-cognitive vulnerability mechanisms serve as a link between parental CD and
offspring schizophrenia (Nuechterlein & Dawson 1984). Communication disturbances in
the parents are thus a sign of shared genetic vulnerabilities (Nuechterlein & Dawson
1984, Subotnik et al. 2002). The fourth model postulates the parents’ CD to be a
reflection of their own psychopathology (Miklowitz & Stackman 1992). Previous studies
have not conclusively supported the reactivity (model two) or parental psychopathology
(model four) models (Wynne et al. 1977, Doane & Rehhaut 1981). Especially the
previous results concerning the stability of CD make the reactivity model questionable.
CD was found to be stable during adulthood over an 11-year follow-up (Wahlberg et al.
2001). Furthermore, Wahlberg et al. (1997) showed that the genetic vulnerability of an
adoptee did not affect the communication patterns of the adoptive parents. Wahlberg et al.
(2004) indicated the genotype interaction to be a more significant predictor of adoptee
pathology than either high genetic risk or CD of the adoptive parents alone.
The systematic interpretation is that parental CD as an interactive environmental
factor and the child’s genetic vulnerability have a synergistic effect on the child’s
cognitive development (Wahlberg 1994). Furthermore, the main responsibility for
interaction belongs to the parents (Wahlberg 1994). Naturally, a stable high level of
parental CD creates a specific environment, which shapes the development of the child’s
thought processes.
2.4 Summary of the literature reviewed
Previous studies have clearly pointed out the possibility of thought disorder as one of the
signs of vulnerability to schizophrenia. Furthermore, it is known that thought disorder is
not a unique characteristic of schizophrenia but also appears in individuals with other
psychiatric disorders as well as in healthy individuals during anxiety or fatigue. However,
the predictive value of thought disorder among other psychiatric disorders has not yet
29
been studied. It has also become apparent that thought disorder has both qualitative and
quantitative aspects. More information is still needed to clarify specifically the kinds of
thought disorder that could be conclusive signs of vulnerability to mental disorders.
Furthermore, the data about the stability of thought disorder has been obtained from
studies with rather short follow-up periods. In order to study the predictive value of
thought disorder, longer follow-ups are needed.
Studies concerning the development of thinking have indicated that the child’s
thinking is a result of the interaction between the child and the parents’ communication.
Especially,parental communication deviance (CD) has been found to be an enduring
“environmental” stressor during the child’s development. The association between
thought disorder and CD also needs some clarification in the longitudinal perspective.
3 Aims of the present study
The purpose of this study was to investigate the predictive value of thought disorder
concerning subsequent psychiatric disorder (I), the stability of thought disorder (II, III),
and the association between thought disorder and Communication Deviance (CD) (IV).
The specific research questions were:
1. Could premorbid signs of thought disorder determined by TDI (Thougth Disorder
Index) predict the subsequent manifestation of psychiatric disorders (I)?
2. Are thought disorders present after a 12-year follow-up? Does the genetic liability to
schizophrenia affect the stability of thought disorder (II)?
3. Are thought disorders only stable at certain severity levels and in the presence of
certain schizophrenia factors of the Thought Disorder Index (TDI) scale? What is the
significance of genetic status and the type of psychiatric disorder for the persistence of
TDI severity levels and factors (III)?
4. Are the thought disorders of high- and low-risk adoptees associated with the
Communication Deviance (CD) of the adoptive parents in the longitudinal perspective
(IV)?
4 Materials and methods
4.1 Study population of the Finnish Adoptive

Family Study of Schizophrenia
This investigation is part of the extensive Finnish adoptive family study of schizophrenia
(389 families) (Tienari et al. 1987a, b, 1994, 2000) that focuses on gene-environment
interactions in schizophrenia. The hospital records of the 19 447 women admitted to
Finnish psychiatric hospitals from January 1, 1960 through 1979 were reviewed to
identify those with a diagnosis of a schizophrenic or paranoid psychosis. Index mothers
who had given one or more offspring up for adoption were identified through every
census and parish register in the country. Women were excluded if they had an organic
brain syndrome, severe mental retardation, primary alcoholism (preceding
schizophrenia), or any other major physical illness (Tienari et al. 1987a, b, 2000, 2003).
Once the adoptees at high risk (HR) for schizophrenia had been identified, their
adoptive parents were eligible for the study with no diagnostic exclusion criteria (Tienari
et al. 2000). Low-risk (LR) adoptees and their adoptive parents consisted of families in
which the adoptees had been adopted away by biological mothers with non-spectrum
diagnoses or no psychiatric disorder. No diagnostic exclusion criteria of either physical or
mental illness were applied to the control adoptive parents. Adoptees were excluded if
they had been adopted by a relative, adopted abroad, or adopted after the age of 4 years.
The final sample included 190 genetically high-risk (HR) offspring whose biological
mothers had verified DSM-III-R diagnoses of the broad schizophrenia spectrum (n=174
(Kendler et al. 1996, Tienari et al. 2000, 2003). The broad schizophrenia spectrum
included the following diagnoses: DSM-III-R schizophrenia, odd-cluster personality
disorders (schizotypal, schizoid, and paranoid personality disorders plus avoidant
personality disorder), nonschizophrenic nonaffective psychoses (schizoaffective,
schizophreniform, and delusional disorders and psychotic disorder not otherwise
specified), and affective psychoses (bipolar and depressive disorders with psychotic
features). The HR offspring were blindly compared with the 192 adoptees at low genetic
risk (LR) whose biological mothers had nonspectrum diagnoses or no psychiatric
disorder (n=190).
32
All available adoptees were evaluated twice. At the initial assessment the adoptees’
median ages were 26 years (IR=18-36) for the HR adoptees and 22 years (IR=17-33) for
the LR adoptees (Tienari et al. 2003). Correspondingly, the median age at the follow-up
evaluation was 44 years (IR=36-52) for the HR and 43 years (IR=37-51) for the LR
adoptees. Of the high-risk adoptees, 92 were male and 98 female, whereas 90 of the LR
adoptees were male and 102 were female (Tienari et al. 2003).
4.2 Procedure of the study
All available biological mothers and biological fathers at high risk (HR) and low risk
(LR) for schizophrenia were personally interviewed (Tienari et al. 1987a,b). The
interviewers of the biological parents were experienced psychiatrics trained in diagnostic
interviews for the Present State Examination (PSE) (Wing et al. 1974), they were
provided training, and interrater reliability checks were performed at Maudsley Hospital
in London (Tienari et al. 1987a,b). The initial and subsequent hospital and clinic records
as well as personal interviews were used to make the research diagnoses according to the
DSM-III-R. In addition, the diagnoses and the diagnostically relevant information have
been checked based on the register data available for all study subjects (Tienari et al.
2000). The parental communication patterns were also evaluated by using the Rorschach
test.
The evaluations of the adoptees’ psychiatric status and thought disorders were part of
the study. The psychiatric assessment included personal interviews, a review of possible
hospital records and registers, and interviews with family members and other informants.
A psychological evaluation, including an individual Rorschach test, was also performed.
All evaluation procedures were carried out in the adoptive families’ home.
The adoptees were independently re-examined in the same manner after a median
interval of 12 years (Interquartile range, IR=8-15). Thereafter, the adoptees’ psychiatric
diagnoses and diagnostically relevant information were followed up until the end of the
year 2000 from national health and hospital registers. The median follow-up period was
18 years (IR=15-21). The follow-up interview schedules included an expanded lifetime
version of the Present State Examination (Wing et al. 1974), the Structured Clinical
Interview for DSM-III-R Personality Disorders (Spitzer & Williams 1986), and the
Structured Interview for Schizotypy (Kendler et al. 1989).
4.3 Study samples in the original publications I-IV
Study sample in original publication I. The study sample included the adoptees without
any psychiatric disorder at the initial assessment who had been administered the
Rorschach test (n=171). Of these subjects, 75 were HR and 96 were LR adoptees. The
median age of the adoptees was 21 years at the initial assessment (Interquartile range,
IR=16-29) (mean=23, sd±9.2), 34 years at follow-up assessment (IR=28-43) (mean=35,
sd±9.3), and 42 years at register follow-up (IR=35-50) (mean=42, sd±9.4). Their median
age at placement in the adoptive families had been 12 months (IR=5-24) (mean=17,
33
sd±14.4). There were 90 were female and 81 male adoptees. The social status of the
adoptive families was rated by using a Finnish classification of the main provider’s
occupation and education (Handbook for Office of Statistics 17, 1983). This classification
is based on the social status of occupations. The first group included people in managerial
positions; the second included entrepreneurs, foremen, and higher officials; the third
included skilled workers and lower officials; and the fourth comprised unskilled workers.
Accordingly, 11% of the families were rated as being in social class I, 47% in class II,
37% in class III, and 5% in class IV. The median follow-up interval in this subsample was
12 years (IR=7-15) (mean=11, sd±4.1). There were no statistically significant differences
in the demographic variables (age, age at placement, gender, and social group) between
the HR and LR adoptees. A comparison of the demographic variables of the adoptees in
this subsample and in the whole sample revealed no statistically significant differences,
except in the adoptees’ age. The adoptees in this study were younger (median age=21
years, IR=16-29) than those in the whole sample, and this variable was therefore
controlled in the multivariate model (logistic regression analysis).
Study sample in original publications II-III. This subsample included the 158 adoptees
whose thought disorder had been assessed by Thought Disorder Index (TDI) both at the
baseline of the study and at follow-up. A further inclusion criterion was that the
Rorschach records had been tape-recorded and transcribed. Of these subjects, 78 were
high-risk (HR) and 80 low-risk (LR) adoptees. The median age of the adoptees was 22
years at the initial assessment (IR=17-32) (mean=25, sd±9.8) and 36 years at the follow-
up assessment (IR=31-45) (mean=37, sd±9.8). Their median age at placement in the
adoptive families was 13 months (IR=6-24) (mean=17, sd±13.4). There were 86 were
female and 72 male adoptees. The distribution of the social groups of the adoptive
families were as follows: social group I 13%, social group II 48%, social group III 32%,
and social group IV 7%. The median follow-up interval in this subsample was 12 years
(IR=8-14) (mean=11, sd±3.8). A comparison of the demographic variables of the
adoptees in this subsample and in the whole sample revealed no statistically significant
differences. The HR adoptees did have significantly more psychiatric disorders than the
LR adoptees at follow-up (p=.01; χ2 test, two-tailed significance). (II, III Table 1)
Study sample in original publication IV: This study sample included the adoptees
whose thought disorder had been assessed at both initial and follow-up evaluations by
using the Thought Disorder Index (TDI). The inclusion criterion was that the Rorschach
records had been tape-recorded and transcribed. Furthermore, the assessment of
communication deviance (CD) of both adoptive parents was relevant. Three single-parent
families who had never had an adoptive father were also included. In these cases, the CD
of the tested adoptive mother was multiplied by two to get a CD score comparable to two
parents’ combined CD score. The final subsample included 89 adoptees. Of the subjects,
38 were high-risk (HR) and 51 low-risk (LR) adoptees. The median follow-up interval in
this subsample was 13 years (IR=9-14) (mean=12, sd±3.6). The adoptees’ median age
was 18 years at the initial assessment (IR=16-23) (mean=20, sd±6.7) and 33 years at the
follow-up assessment (IR=28-37) (mean=33, sd±7.9). Their median age at placement in
the adoptive families was 12 months (IR=5-23) (mean=16, sd±13.5). There were 50
female and 39 male adoptees. The socal group distribution of the adoptive families was as
follows: social group I 9%, social group II 53%, social group III 34%, and social group
34
IV 4%. The HR adoptees had significantly more psychiatric disorders than the LR
adoptees at follow-up (p=.004; χ2 test, two-tailed significance). (IV Table 1)
4.4 Variables
The Rorschach test was used to evaluate both the adoptees’ thought disorder and the
adoptive parents’ communication patterns. The assessments were performed according to
Klopfer & Davidson (1962) and Singer & Wynne (1986) in order to evaluate the degree
of communication deviance (Appendix 1). The interview and testing sessions were tape-
recorded. and the tapes were transcribed verbatim. The psychiatrists administered the
Rorschach test with a complete set of ten cards. They were trained to do this by an
experienced clinical psychologist (Karl-Erik Wahlberg).
The Thought Disorder Index (TDI) was used to assess the adoptees’ thought disorders.
The scoring of TDI at the initial assessment was done by four experienced psychologists
(Heljä Anias-Tanner, Pekka Koistinen, Taneli Tarvainen, Karl-Erik Wahlberg) pairwise
unaware of the subjects’ relatedness to their biological and adoptive families or their
psychiatric diagnoses. They only knew the subjects’ age, sex, and occupation. The TDI
instrument has not been used before in Finland, and an enormous amount of work had to
be done to adapt the TDI questionnaire to the Finnish language and culture (Wahlberg
1994, Koistinen 1995). A procedure of detemining the reliability of the scores between
the raters was also developed. These operations were done in co-operation with Dr. P.S.
Holzman (one of the developers of the scale) and the Drs Wynne and Singer. In cases of
disagreement concerning the scoring, a consensus score was negotiated between the
psychologists (Wahlberg 1994). The scoring of TDI at follow-up was made by one
psychologist (M.Metsänen), again unaware of the subjects’ relatedness to their biological
and adoptive families and their psychiatric diagnoses. As at the initial assessment, she
only knew the subjects’ age, sex, and occupation. Furthermore, she was blind to the
ratings of the other psychologists. M. Metsänen was trained by K-E Wahlberg, P.
Koistinen, and T. Tarvainen to use the TDI scoring system. In the training process, a large
number of Rorschach records were reviewed, and the reliability study was done by using
20 records.
The communication patterns of the adoptive parents was assessed for Communication
Deviance (CD). Dr Singer and Dr Wynne trained Dr Wahlberg in the scoring of CD, and
the minor modifications of the scoring in Finnish compared to English were discussed
(Wahlberg 1994). The scoring was carried out by two psychologists (K-E. Wahlberg, P.
Keskitalo) unaware of the participants’ status in accordance with the manual of Singer
and Wynne (1986). The Finnish translation of the CD manual was also produced as team
work between the Finnish psychologists (K-E. Wahlberg, P. Keskitalo) and the Drs Singer
and Wynne (Wahlberg 1994, Keskitalo 2000).
The adoptees’ psychiatric status was assessed by psychiatrists blind to their high-
risk/low-risk status and other background information. The diagnoses were made
according to the DSM-III-R criteria (American Psychiatric Association 1987).
35
4.4.1 Thought Disorder Index (I-IV)
The Thought Disorder Index (TDI) identifies 23 different items weighted along a
continuum of severity (0.25, 0.50, 0.75 and 1.0) (Johnston & Holzman 1979, Solovay et
al. 1987) (Table 1). The 0.25 severity level represents minor idiosyncrasies. It is very
common that even healthy individuals make comments at the 0.25 level, especially under
anxiety or fatigue. At the 0.50 severity levels, responses indicate a loss of mooring, shaky
reality contact, emotional overreaction, and distinct oddness but are still in reality
(Solovay et al. 1986). The 0.75 level is associated with psychotic disruption and
characterized by instability of thinking and perception, absurdity, and an unrestrained
combinatory tendency (Solovay et al. 1986). The 1.0 level represents responses
completely out of reality (Solovay et al. 1986).
The developers of the TDI scale (Johnston & Holzman 1979, Holzman et al. 1986,
Solovay et al. 1986) used weighted scores, and to calculate total TDI (TDR), the
following formula was applied in this study:
0.25 (A) + 0.50 (B) + 0.75 (C) + 1.00 (D)

TD R = × 100
Total number of Rorschach responses
where A=the number of responses scored at the level 0.25, B=the number of responses
scored at the level 0.50, C=the number of responses scored at the level 0.75, and D=the
number of responses scored at the level 1.00.
Every severity level was calculated by summing up the relevant item scores and
dividing the sums by the number of responses.
Holzman et al. (1986) constructed a set of factors from the TDI categories that
discriminated best between schizophrenic and manic patients. They were able to
construct three factors that were conceptually characteristic of schizophrenic patients:
fluid thinking, confusion, and idiosyncratic verbalization. Each factor scale was
calculated by summing up all relevant thought disorder item scores and dividing the sums
with the number of responses. Fluid thinking includes the TDI items 9 (Relationship
verbalization), 17 (Fluidity), and 21 (Contamination), confusion the items 5 (Word-
finding difficulty), 12 (Confusion), 18 (Absurd responses), and 23 (Neologisms), and
idiosyncratic verbalization item 4 (Peculiar verbalizations and responses).
36
Table 1. a) Thought Disorder Index levels and categories (I Table 1).
0.25 level 0.50 level
1. Inappropriate distance 8d. External-internal response
a. Increase of distance 9. Relationship verbalization
b. Excessive qualification 10. Idiosyncratic symbolism
c. Concreteness a. Color symbolism
d. Overspecificity b. Image symbolism
e. Syncretistic response 11. Queer responses
2. Flippant response a. Queer expressions
3. Vagueness b. Queer imagery
4. Peculiar verbalizations and responses c. Queer word usage
a. Peculiar expression 12. Confusion
b. Stilted, inappropriate expression 13. Looseness
c. Idiosyncratic word usage 14. Fabulized combinations, impossible or bizarre
5. Word-finding difficulty
6. Clangs 15. Playful combinations
7. Perseveration 16. Fragmentation
8. Incongruous combinations
a. Composite response
b. Arbitrary form-color response
c. Inappropriate activity response
Table 1. b) Thought Disorder Index levels and categories (I Table 1).

0.75 level 1.0 level
17. Fluidity 21. Contamination
18. Absurd responses 22. Incoherence
19. Confabulations 23. Neologisms
a. Details in one area generalized to larger area
b. Extreme elaboration
20. Autistic logic
4.4.2 The validity and reliability of TDI
Thought Disorder Index (TDI) has been found to be a valid indicator of disordered
thinking in schizophrenic patients (Holzman et al. 1986, Shenton et al. 1987, Hurt et al.
1983, Hain et al. 1995). The validity of TDI among schizophrenic patients has been
confirmed: schizophrenic patients had elevated levels of thought disorder in all categories
and at all severity levels, while normal controls demonstrated only rare instances of
disordered thinking in most domains. Furthermore, different factors have turned out
useful in distinguishing between diagnostic groups (Holzman et al. 1985, Shenton et al.
1987, Solovay et al. 1987). Studies on the reliability of TDI have reported the inter-rater
reliabilities for total TDI scores to range from 0.82 to 0.93 (Johnston & Holzman 1979,
37
Solovay et al. 1986, Coleman et al. 1993). Furthermore, Solovay et al. (1986) reported
individual scoring categories of 0.81, severity levels of 0.79, and various factor scores
ranging from 0.84 to 0.89.
In this study, the intraclass correlation (ICC) between the pairs of psychologists at the
initial assessment was 0.94 for TDR, 0.92 for 0.25 level, 0.92 for 0.50 level, 0.86 for 0.75
level, 0.66 for 1.0 level, 0.95 for fluid thinking, 0.33 for confusion, and 0.80 for
idiosyncratic verbalization (n=59). The reason for the low reliability at the 1.0 level and
in confusion was the restricted range in these categories (most subjects had 0 scores), not
frequent disagreements between the scorers. Most of the records were randomly selected
for reliability analysis, except the 15 records of schizophrenic patients. These were
included in the reliability sample to ensure that there were also records with several types
of thought disorder. Reliability was also checked (every 20. record) (n=31) at follow-up
by the single-measure ICC between the two psychologists (M. Metsänen and K-E
Wahlberg). The ICCs were 0.98 for TDR, 0.85 for 0.25 level, 0.92 for 0.50 level, 0.95 for
0.75 level, 0.83 for fluid thinking, 0.86 for confusion, and 0.49 for idiosyncratic
verbalization. The 1.0 severity level was omitted because only one subject had scores at
this level at the initial assessment.
4.4.3 Communication Deviance (IV)
Communication Deviance of both adoptive parents was assessed from tape-recorded

individual Rorschach test protocols, which had been transcribed according to the
standardized instructions (Appendix 1). In this study, only the CD scores recorded during
the test part of the Rorschach were taken into account. The reason for this was that, in
many families, the inquiry had been made only partly or not at all because of the
informants’ fatigue. Furthermore, the inquiries often included a large proportion of the
examiner’s speech, and it was thus difficult to evaluate reliably the subjects’
communication deviance.
Communication deviance (CD) includes 42 items (Singer & Wynne 1966, Singer et al.
1978, M.T. Singer and L.C.Wynne, unpublished 1986 version). These items have been
divided into the following six groups (Table 2):
− Disruptions of the Task and the Relationship with the Tester
− Problems of Commitment and Sustaining Task
− Unclear and Unstable References
− Language Anomalies
− Reasoning Problems and Contradictions
− Indefinite and Cryptic Comments
Every item was searched from the transcribed text, and the presence of an item was
scored as one point. All speech in a response given by the subject was recorded as a
transaction. The total CD was calculated separately for each parent as the frequency of
the scored CD items divided by the number of transactions in the individual Rorschach
test. The quotients were used as the CD for each parental pair. The intra-class coefficient
for CD between the psychologists in this study was 0.95 (51 records scored).
38
Table 2. Communication deviance (CD)
CD categories
I Disruptions of the Task and the Relationship with the Tester
Put-down of the tester of the task
Interruptions of the examiner’s speeches
Extraneous questions and remarks
Nonverbal disruptive behavior
Environmental task disruptions
Disruptive humor
Disruptive swearing
Other conversation stoppers
II Problems of Commitment and Sustaining Task
Abandoned, abruptly ceased, uncorrected remarks
Responses in negative form
Subjunctive, “if” responses
Question responses
Nihilistic remarks about task or life in general
Inability or failure to verify own responses
Forgetting responses
Answering unasked questions
Hopping around among responses
Negativistic, temporary card rejection followed by a response
Concrete-set responses
Assigning to other responsibility for the percept
III Unclear and Unstable References
Unintelligible remarks: a) brief, without context, or b) the total effect ending with an unintelligible referent
Unstable percepts
Inconsistent and ambiguous references
Incompatible alternatives or incompatible aspects of images
Derogatory, disparaging, critical disqualifications of a response
Nihilistic remarks
Partial disqualification
IV Language Anomalies
Ordinary words or phases used oddly, incorrectly, or out of context
Odd sentence construction
Private, contrived terms and labeling
Clang associations, rhymed phrases, and word play
Reiteration
V Reasoning Problems and Contradictions
Contradictory information
Retractions and denials
Odd, tangential, inappropriate responses to questions or remarks
Peculiar logic; illogical combinations or percepts
Non sequitur reasoning
Assigning meaning on the basis of nonessential attributes of the cards
Contaminations
VI Indefinite and Cryptic Comments
Gross indefiniteness and lack of specificity
Cryptic remarks
Abstract, global terms and technical phrases
39
4.4.4 DSM-III-R diagnoses of the adoptees (I-IV)
The diagnoses of the adoptees were made according to the DSM-III-R criteria (American
Psychiatric Association 1987) based on the personal interviews (Tienari et al. 2000). The
interview schedules included an expanded lifetime version of the PSE (Wing et al. 1974),
Structural Clinical Interview for DSM-III-R Personality Disorders (SCID-II) (Spitzer et
al. 1989), and the Structured Interview for Schizotypy (SIS) (Kendler et al. 1989). The
DSM-III-R diagnoses were made according to the best estimate of the most severe
lifetime Axis I (clinical syndromes) or Axis II (developmental disorders and conditions,
personality disorders) psychiatric disorder based on all available data (psychiatric
hospital records, research interviews). Comorbid and supplementary diagnoses were also
applied. The diagnoses were made at maximum certainty, i.e. the disorder had to be
diagnosed as probable or definite. The kappa coefficient for inter-rater reliability varied
between the different raters, ranging from 0.71 to 0.80 (Tienari et al. 2000).
Original paper I: The adoptees were divided into three major diagnostic groups. The
diagnostic hierarchy of disorders was established in line with the suggestions of Kendler
et al. (1996). The first group consisted of the subjects without psychiatric disorder (No
Psychiatric Disorder, NPD) at either the initial or the follow-up assessment (n=130). The
second group (n=33) consisted of adoptees with Any Other Psychiatric Disorder (AOPD)
except the broad spectrum of schizophrenia at follow-up. The second group consisted of
borderline (3), antisocial (2), narcissistic (2), histrionic (5), and obsessive-compulsive (2)
personality disorders, personality disorder NOS (2), anxiety (6), alcohol (3), mild mood
(6), and dysthymic (2) disorders. The third group comprised subjects with Broad
Schizophrenia Spectrum Disorders (BSSD) (n=8) and included cases with schizophrenia
(1), paranoid (2), avoidant (2), and schizoid (1) personality disorders, bipolar psychosis
(1), and depressive psychosis (1). The second and third groups together constituted the
group of adoptees with Any Psychiatric Disorder (APD).
Original paper II-III: The study sample was divided into two diagnostic groups. The
first group consisted of adoptees without Any Psychiatric Disorder (No Psychiatric
Disorder, NPD) (n=87). All possible diagnoses were excluded from the NPD group in
order to study the stability of TDI in a maximally healthy sample. The second group
included adoptees with Any Psychiatric Disorder (APD) (n=87). The distribution of the
APD group was as follows: schizophrenia (3), schizotypal (1), paranoid (2), schizoid (2),
avoidant (4), antisocial (6), borderline (7), narcissistic (4), histrionic (5), dependent (2),
and obsessive-compulsive (2) personality disorders, personality disorder NOS (4), bipolar
(2), and depressive (1) psychosis, anxiety (10), alcohol (5), mild mood (7), dysthymic (5),
eating (1), somatoform (2), and other (12) psychiatric disorders.
Original paper IV. The adoptees were divided into two diagnostic groups. The first
group included adoptees without any psychiatric disorder (NPD; at the initial assessment
n=74, at follow-up n=53). The second group consisted of adoptees with any psychiatric
disorder (APD). The APD group included the adoptees with the following diagnoses at
the initial assessment (n=15): schizophrenia (1), bipolar psychosis (1), antisocial (2),
borderline (1), and dependent (2) personality disorders, personality NOS (1), anxiety
disorders (3), eating disorders (1), alcohol use (1), and dysthymic disorder (2).
Correspondingly, the distribution of the diagnoses at follow-up was as follows (n=36):
40
schizophrenia (1), paranoid (2), schizoid (1), antisocial (4), borderline (4), narcissistic
(2), histrionic (3), avoidant (2), dependent (1), and obsessive-compulsive (1) personality
disorders, personality disorder NOS (2), mild mood disorders (3), dysthymic disorder (1),
and anxiety disorders (4).
4.5 Statistical methods
The group differences (two independent samples) in the categorical variables were
assessed with the Chi-square χ2 test or Fisher’s Exact test and those in the continuous
variables with Student’s t-test or the Mann-Whitney U-test. The differences between the
initial and follow-up assessments (two related samples) in the continuous and categorical
variables were analyzed with the pair-samples t-test and McNemar’s test, respectively
(McCullagh & Nelder 1989, Bland 1995).
Analysis of covariance (ANCOVA) was used to examine group differences in the
continuous variables after controlling for potential confounders. The Tukey-Kramer
method was used as an adjustment procedure for multiple testing in ANCOVA.
(Tabachnick & Fidell 1989). Logistic regression analysis was used to assess the statistical
significance of an association of the independent categorical and continuous explanatory
variables with the dichotomous outcome variable (Kleinbaum 1994). Receiver operating
characteristic (ROC) curve analysis was done to find the best cut-off point for each TDI
subscale (Gniner et al. 1981).
All statistical analyses were performed using the SPSS (version 9.0, 11.0, 12.0) and
the SAS version 8.2 version (SAS Institute, Cary, NC).
4.6 Ethical considerations
The Finnish Adoptive Family Study was approved by the Ethics Committee of the
Medical Faculty of the University of Oulu (Finland). The sample used in the study
already existed. Thus, there was no need to meet personally the study subjects of the
study. The ethical considerations of this study are related to the use of the achieved
results in possible preventive work in the future. Collaboration with the people at risk to
develop a psychiatric disorder at follow-up and their relatives is extremely important. The
goal of preventive work is not to control their lives but to provide ways to support their
mental health. The relatives of these persons could also learn new ways to help their
family member at risk. Furthermore, it is essential to emphasize that not all people with
risk factors eventually develop a psychiatric disorder.
41
4.7 Personal involvement
I have been participating in the Finnish Adoptive Family Study of Schizophrenia since
2000. I have scored all follow-up TDI records, completed the reliability studies of the
follow-up TDI records, performed statistical analyses, interpreted the results, and written
all manuscripts with consultation of co-workers.
5 Results
5.1 Premorbid signs of thought disorder and psychiatric

disorder at follow-up (I)
High scores at the initial assessment were shown to be statistically significantly more
common among the adoptees with a follow-up diagnosis of ‘Any Psychiatric Disorder’
(APD, n=41) than among the adoptees with ‘No Psychiatric Disorder’ (NPD, n=130) at
follow-up on the following TDI measures: TDR (APD vs. NPD, 61% vs. 43%, χ2 test ,
df=2, p=.05), the 0.50 severity level (71% vs. 51%, χ2 test , df=2, p=.03), and
idiosyncratic verbalization (63% vs. 40%, χ2 test , df=2, p=.01) (I Table 2). These
differences were especially prominent in a comparison of the adoptees with ‘Any Other
Psychiatric Disorder’(AOPD, n=33) to the NPD adoptees: TDR (AOPD vs. NPD, 64%
vs. 43%, χ2 test, p=.04), 0.50 severity level (70% vs. 51%, χ2 test, p=.05), and
idiosyncratic verbalization (61% vs. 40%, χ2 test, p=.03). No statistically significant
difference in these TDI measures was seen between the adoptees with ‘Broad
Schizophrenia Spectrum Disorder’ (BSSD, n=8) and the NPD adoptees.
The TDI scores of the high-risk (HR) adoptees were not associated with their
subsequent psychiatric status. There was, however, a tendency toward a greater
proportion of HR adoptees with high scores (as compared to low scores) at the initial
assessment to have TDR (63% vs. 37%), 0.25 severity level (95% vs. 5%), and
idiosyncratic verbalization (68% vs. 32%) among the group of AOPD adoptees observed
at follow-up. (Table 3: I Table 3; The table of the original article included a misprint in
the result of the 0.25 severity level, which has now been corrected).
43
Table 3. Percentage (%) and number (n) of high and low initial TDI variables of the
high-risk adoptees in the different groups of mental disorders (n=75)(I Table 3)
TDI variables NDPa AODPb BSSDc p-values
n=50 (67%) n=19 (25%) n=6 (8%)
% n % n % n
TDR
high 48.0 24 63.2 12 50.0 503
low 52.0 26 36.8 7 50.0 3 0.33
0.25
high 88.0 44 94.7 18 100.0 6
low 12.0 6 5.3 1 0.0 3 0.41e
0.50
high 50.0 25 57.9 11 66.7 4
low 50.0 25 42.1 8 33.3 2 0.41
0.75
high 40.0 20 47.4 9 16.7 1
low 60.0 30 52.6 10 83.3 5 1.0
fluid thinking
high 30.0 15 31.6 6 16.7 1
low 70.0 35 68.4 13 83.3 5 0.86
confusion
high 12.0 6 0.0 0 16.7 1
low 88.0 44 100.0 19 83.3 5 0.41e
idiosyncratic
verbalization
high 50.0 25 68.4 13 66.7 4
low 50.0 25 31.6 6 33.3 2 0.14
a no psychiatric disorder at the initial assessment and at follow-up
b no psychiatric disorder at the initial assessment and any other psychiatric disorder at follow-up
c no psychiatric disorder at the initial assessment and broad schizophrenia spectrum disorder at follow-up
d no psychiatric disorder at the initial assessment and any psychiatric disorder at follow-up
e Fisher’s exact test
Furthermore, 87.5% of the low-risk (LR) adoptees with a follow-up diagnosis of APD
(n=16) had high scores on the 0.50 severity level at the initial assessment, while the
respective proportion of high scores among the NPD adoptees (n=80) at follow-up was
51% (χ2 test, p=.01). This difference was especially obvious among the adoptees in the
AOPD group (n=14) (AOPD vs. NPD, 86% vs. 51%, χ2 test, p=.02). Similarly to the HR
adoptees, high scores on the TDI measures at the initial assessment were found to be
more common among the LR adoptees with a follow-up diagnosis for mental disorders (I
Table 4)
Logistic regression analysis was used to predict the follow-up psychiatric status of the
adoptees with genetic liability for schizophrenia and different TDI variables measured at
the initial assessment. The statistically significant associations are presented in Table 4.
44
Table 4. Adjusted odds ratios (OR) for different high TDI scores of the adoptees with
predictors of genetic liability for schizophrenia at the initial assessment and interaction
of TDI scores and genetic liability for any psychiatric disorder (APD) at follow-up.
Variable Adjusted 95% Confidence p
Odds Ratio* Interval
high TDR 2.20 1.06-4.58 0.04
genetic liability 3.34 1.04-10.81 0.04
interaction for TDR and genetic liability 0.61 0.13-2.86 0.53
high 0.50 severity level 2.68 1.23-5.85 0.02
interaction for 0.50 severity level and genetic 0.20 0.03-1.31 0.09
liability
high idiosyncratic verbalization 2.55 1.22-5.31 0.02
interaction for idiosyncratic verbalization and 0.87 0.19-4.04 0.86
genetic liability
* Odds ratios with 95% confidence interval from a logistic regression model predicting the likelihood for the
adoptee’s psychiatric disorder at follow-up with different TDI variables and the genetic liability for
schizophrenia (high-risk, low-risk).
5.2 Stability of thought disorder (II, III)
The stability of the adoptees’ thought disorder between the initial and follow-up
assessments was investigated using the total TDR scores, the severity levels (0.25, 0.50
and 0.75), and schizophrenia factors (fluid thinking, confusion, idiosyncratic
verbalization) separately.
At the baseline, the variation of the total TDR score was shown to associate
statistically significantly only with female gender (ANCOVA, F-statistic = 10.52, p =
0.002), but not with any other main effects (genetic risk, psychiatric status), age at the
initial assessment, or any interactions between genetic risk, gender, and psychiatric status
(II Table 2). At follow-up, only the baseline TDR explained the variation of the total TDR
at follow-up, but none of the main effects, age at follow-up, or interaction terms did
(Table 5: II Table 3).
45
Table 5. Total TDI (TDR) scores at follow-up assessment and their association with
genetic risk, gender and psychiatric status of the adoptees. (II Table 3)
TDR at follow-up N Adj. mean (SE) ANCOVA*
for main effects F-statistic p-value
Corrected model * 158 1.28 0.25
Main effects
Genetic risk
LR 80 7.19 (0.76) 0.04 0.84
HR 78 6.97 (0.77)
Gender
Girl 86 6.55 (0.73) 0.92 0.34
Boys 72 7.61 (0.82)
Psychiatric status at follow-up
No psychiatric disorder (NPD) 71 7.44 (0.81) 0.44 0.51
Any psychiatric disorder (APD) 87 6.71 (0.74)
Interactions
Genetic risk*Gender 0.26 0.61
Genetic risk*Psychiatric status 2.86 0.09
Gender*Psychiatric status 0.02 0.89
Genetic risk*Gender*Psychiatric status 1.46 0.23
Covariates
TDR at initial assessment 5.21 0.02
Age at follow-up 1.96 0.17
* ANCOVA was used to assess the statistical significance of the mean difference in follow-up scores between
the groups (genetic risk, gender, psychiatric status) after adjustment for TDR at the initial assessment and the
adoptee’s age at follow-up and correction for multiple comparisons with the Tukey-Kramer method
The TDI scores at all TDI severity levels decreased between the initial and follow-up
assessments (III Table 2). However, stability of the scores between the initial and follow-
up assessments was seen at the 0.50 and 0.75 severity levels, but not at the 0.25 severity
level (Figure 1: III Figure 1). The adoptees’ genetic or psychiatric status was not
associated with the results (III Table 3).
46
a) The 0.25 severity level of the TDI scale
b) The 0.50 severity level of the TDI scale
5
5
4
TDI score at follow-up assessment

3
3
2
2
1
1
0
-1 0
-2 -1
-2 -1 0 1 2 3 4 5 -1 0 1 2 3 4 5
TDI score at baseline TDI score at baseline
c) The 0.75 severity level of the TDI scale

5
4
-1
-1 0 1 2 3 4 5
TDI score at baseline
Fig. 1. Relationship of the TDI scores between the initial (baseline) and follow-up assessments
at the a) 0.25, b) 0.50, and c) 0.75 severity levels of the TDI scale (III Figure 1).
Correspondingly, despite the decreased scores of all Holzman’s schizophrenia factors (III
Table 4), only idiosyncratic verbalization was shown to remain stable between the initial
and follow-up assessments, and this stability was not related to the adoptee’s genetic or
psychiatric status. (Table 6: III Table 5)
47
Table 6. Association of Holzman’s schizophrenia factors on the TDI scale between the
initial and follow-up assessments among the adoptees. (III Table 5)
Schizophrenia factors OR (95%CI) P-value
Fluid thinking
Model 1, unadjusted* 2.29 (0.87-6.05) 0.09
Model 2, adjusted ** 2.34 (0.84-6.54) 0.11
Confusion
Model 1, unadjusted 2.22 (0.43-11.56) 0.34
Model 2, adjusted 2.05 (0.38-10.99) 0.40
Idiosyncratic verbalization
Model 1, unadjusted 2.16 (1.13-4.15) 0.02
Model 2, adjusted 2.33 (1.19-4.53) 0.01
* Model 1: In each schizophrenia factor, binary logistic regression analysis (odds ratios, OR, and 95%
confidence intervals, CI) was used to assess the association between the TDI at follow-up assessment (as
outcome) and the TDI at baseline.
**Model 2: In each schizophrenia factor, binary logistic regression analysis (OR, 95% CI) was used to assess
the association between the TDI at follow-up assessment (as outcome) and the TDI at baseline after controlling
for gender, age, and genetic and psychiatric status and their interactions.
5.3 Association between parental Communication Deviance (CD)

and adoptee’s thought disorder (IV)
The effect of the adoptive parents’ Communication Deviance (CD) on the adoptee’s total
TDR scores was discussed in the original publication IV. The upper quartiles in the
distribution of both the adoptees’ TDR and the parents’ CD were defined as the most
deviant extremes of these variables (high TDR, high CD).
At the initial assessment, the proportion of adoptees with high TDR scores was about
twofold if the adoptive rearing parents had high CD scores compared to the rearing
parents with low CD scores (40.9% vs. 19.4%, χ2-test, p-value = 0.04). However, this
difference in proportions was no longer present at follow-up (IV Table 2).
The LR adoptees reared by adoptive parents with high CD scores were shown to have
a statistically significantly increased likelihood for high TDR scores at follow-up, while
no association was seen in the HR adoptees. Additional analyses of male and female
adoptees separately revealed no significant association between parents’ CD and
adoptees’ TDR at follow-up. (Table 7: IV Table 3)
48
Table 7. Association between high Communication Deviance (CD) scores of adoptive
parents at initial evaluation and likelihood for high scores in Thought Disorder Index at
follow-up among low- and high-risk adoptees in the Finnish Adoptive Family Study of
Schizophrenia (IV Table 3).
Variable LR adoptees (n=51) HR adoptees (n=38)
OR (95% CI) p-value OR (95%CI) p-value
High CD of adoptive parents 6.92 (1.30 - 36.89) 0.02 0.21 (0.02 - 2.04) 0.18
Psychiatric status (APD) 2.76 (0.56 - 13.60) 0.21 1.38 (0.22 - 8.53) 0.73
Gender, male 1.06 (0.23 - 4.81) 0.94 0.99 (0.19 - 5.06) 0.99
Age at follow-up 1.10 (0.98 - 1.23) 0.11 1.03 (0.93 - 1.14) 0.62
Social status of the adoptive 1.08 (0.23 - 5.04) 0.92 0.85 (0.17 - 4.34) 0.84
family
Note: High TDR and high CD indicate the scores belonging to upper quartile of the distribution of a variable.
6 Discussion
6.1 Discussion of the results (I-IV)
6.1.1 Thought disorder as a prospective sign of mental disorder (I)
High scores on several TDI variables at the initial assessment predicted psychiatric
disorder at follow-up in all adoptees. These results are consistent with the previous
studies, which have suggested that thought disorder is related to psychiatric disorders
(Holzman et al. 1986, Arboleda & Holzman 1985, Solovay et al. 1987, Koistinen 1995,
Wahlberg et al. 2000). However, the early presence of any TDI variable did not alone
predict broad schizophrenia spectrum disorder at follow-up. Thus, it is very important to
recognize that elevated scores on different TDI variables can predict an increased risk to
develop any psychiatric disorders, including schizophrenia spectrum disorders. The
reason for the results obtained here could be the limited size of our sample. Only eight
cases of broad-spectrum schizophrenia were present. Prediction was statistically
unsuccessful among the high-risk (HR) adoptees because of the small number of cases,
but high scores at the 0.50 severity level did predict mental disorders among the low-risk
(LR) adoptees. However, HR adoptees did have a higher risk to have any psychiatric
diagnosis at follow-up than LR adoptees. The result is consistent with the previous
findings of the Finnish Adoptive Family Study of Schizophrenia (Tienari et al. 2000).
The 0.50 severity level had a predictive value. This result was not surprising in view
of the content of this level. The 0.50 level includes responses related to loss of mooring,
shaky reality contact, emotional overreactions, and distinct oddness (Solovay et al. 1986).
These characteristics are considered precursors of future psychosis (Olin & Mednick
1986). The absence of predictive value at the other severity levels was also logical. The
0.25 severity level responses are very general, and most people occasionally make
comments classifiable at the 0.25 level at times of fatigue or anxiety. Correspondingly,
the 0.75 severity level is in itself an obvious sign of severe psychopathology and cannot
therefore be an actually predictive sign of mental disorder.
50
Idiosyncratic verbalization was found to be related to other than broad schizophrenia
spectrum disorders. The result is in line with the findings of Holzman et al. (1986), which
showed idiosyncratic verbalization, fluid thinking, and confusion to be connected with
serious mental disorders. Surprisingly, in this study, fluid thinking and confusion did not
predict any psychiatric disorder. It was even found that the adoptees whose scores were
low on the confusion subscale tended to have some other psychiatric disorder at follow-
up, while the adoptees whose scores were high tended to have no diagnosis at all. This
result can probably be explained by the large number of 0.25 severity level responses
(word finding difficulty) on the confusion subscale in our sample. One theory is that
healthy persons’ thought processing might include such content because they might want
to achieve the best possible result in the test situation, and this might cause more
processing to choose between different words.
6.1.2 Stability of thought disorder (II, III)
The number of thought disorders decreased during the follow-up period. Previous studies
have shown that, in the longitudinal perspective, age had a positive effect on, for
example, verbal ability (Schaie et al. 2004). Thus, the decrease of different TDI scores
might also be related to the maturation of thought functions. Many adoptees were quite
young (mean 25 years) at the initial assessment, and they grew up during the follow-up.
Despite the decrease of thought disorders, the main finding was that the initial TDR scores
statistically significantly predicted the TDR scores at follow-up, thus indicating the
stability of thought disorder over time. Furthermore, a more specific result was that the
stability of TDI seems to be related to the most severe categories of thought disorders.
The adoptees’ genetic or psychiatric status at follow-up did not affect the results. Thus,
genetic risk alone is probably not the only crucial factor underlying the stability of
thought disorder, but environmental factors are needed, too. This result is in the line with
the findings of Wahlberg et al. (2000), which showed idiosyncratic verbalization to be
linked not only with the genetic risk but also with the communication patterns of the
adoptive rearing parents. In our study, only genetic factors were taken into account. The
absence of stability of thought disorders among psychiatric disorders could be explained
by the low number of subjects with schizophrenia and other severe mental disorders in
our study. Marengo & Harrow (1997) especially found thought disorder to be more
prevalent and severe over time in schizophrenia than in nonschizophrenic disorders.
Episodic thought disorder is common among other psychiatric diagnoses, such as
nonpsychotic disorders (Marengo & Harrow, 1987).
An interesting gender-related result was obtained at the initial assessment. Women had
significantly more TDR scores than men. Previously studies have not addressed possible
gender differences, and the reason for this result can hence only be speculated. Yurgelun-
Todd et al. (2002) found sex-specific developmental differences in the relations between
cerebral structure and function, and it is thus possible that, in the initial test situation, the
anxiety experienced by the women was so high that it affected their thought processes.
Previous studies have shown that some psychiatric disorders, such as eating disorders,
anxiety disorders, and depression, including major depression, dysphoria, seasonal
51
affective disorder, posttraumatic stress disorder, panic disorder, and generalized anxiety
disorder, are more common among women (Strober et al. 2000). Although the possible
gender differences in the diagnoses were not investigated here, it could be speculated
whether it is possible that, in a stressful situation, the thought functions of women are
more vulnerable to confusion and more liable to thought disorders. Overall, differences in
specific cognitive functions have been found, as women have relied on emotional content
to a greater degree than men in processing information (Bremner et al. 2001).
The instability of mild thought disorders, such as 0.25 severity level responses, was
not surprising because they are related to state-like features, such as anxiety and fatigue
(Solovay et al. 1986). On the other hand, the lack of stability in fluid thinking and
confusion was rather unexpected. However, these factors are especially related to
schizophrenia, and our sample included only three subjects with schizophrenia diagnosed
at the end of the follow-up. The content of fluid thinking represents thought disorders in
which subject’s perceptions and thought processes are very unstable. Confusion also
reflects very serious vagueness and disorientation in thinking. Thus, changes in thought
disorders, which are characterized by rapid alterations, could also be very understandable.
However, it is assumed that thinking processes are cognitive qualities and hence rather
stable. In addition, the rates of occurrence of fluid thinking and confusion in our sample
were distinctly lower than that of idiosyncratic verbalization. The subjects’ maturation
could also explain the instability of fluid thinking and confusion. The adoptees grew
older during the follow-up period, and their thought processes also became less fluid and
confused. The abilities to manage stress and emotional conflicts develop later in life, and
these abilities have been found to affect the development of cognitive functions (Rowe &
Kahn 1987).
6.1.3 Parental communication deviance and thought

disorders of offspring (IV)
Our result on the association between the adoptees’ thought disorder and parental
Communication Deviance supported the earlier finding of Wahlberg et al. (1997).
However, adoptive parents’ CD at follow-up only predicted thought disorders in the low-
risk (LR) adoptees. It is significant that TDI scores decreased over time despite the stable
nature of thought disturbances, possibly because of the maturation of thought processes.
This phenomenon could also affect the result concerning the long-term association of CD
and TDI scores. Another explanation could be the change in the adoptees’ environment. It
is most probable that the adoptees had moved away from home during the follow-up
period. Thus, they were no longer exposed to the CD of their adoptive parents, but
possibly had a less confusing and thus more “protective” environment. Especially high-
risk (HR) adoptees have been found to be more sensitive to their environment than LR
adoptees (Wahlberg et al. 1997, Tienari et al. 2004). HR adoptees had more thought
disorder than LR adoptees if their adoptive parents had high levels of CD.
Correspondingly, HR adoptees had a lower incidence of thought disorders than LR
adoptees if they were living with low-CD adoptive parents. Thus, it could be speculated
whether the HR adoptees in this study were more sensitive to the possible positive
52
changes in their environment and therefore no longer displayed the association of TDR
with CD at follow-up.
6.2 Strengths and limitations of the studies (I-IV)
The Finnish Adoptive Family Study of Schizophrenia is based on a study design that
provides a rare opportunity to investigate separately genetic and environmental factors,
but also to study the interaction of these variables. The most obvious strength of the
present studies is the possibility to use the unique data obtained during this adoption
study. One strength of the Finnish Adoptive Family Study of Schizophrenia is the long
follow-up time, and the present study has also taken advantage of this. In the previous
studies concerning the stability of thought disorder the follow-up periods have been
rather short (6-7 years). In our studies (II, III) the follow-up time was 11 years. The
Finnish Adoptive Family Study of Schizophrenia has also used extensive and reliable
methods. Furthermore, long follow-up data of Rorschach protocols are very rare. To our
knowledge, the Thought Disorder Index (TDI) has not been used before to assess the
stability of thought disorder in a longitudinal setting (II, III). TDI is a valid indicator of
disordered thinking in schizophrenia, and its reliability has ranged from 0.79 to 0.93.
Although the possibility to use the existing data from the Finnish Adoptive Family
Study of Schizophrenia offers many opportunities and strengths, it also poses some
limitations. First, the sample that offers the possibility to study the predictive value of
thought disorder includes only eight subjects in the broad schizophrenia spectrum group,
and the distribution of diagnoses in the group with any other psychiatric disorder was so
large that it was not possible to study which specific diagnoses the thought disorders were
related to (I). Severe mental disorders were also rare in our stability studies (II, III).
Especially the low number of schizophrenic subjects could clearly bias the results. Again,
the small number of cases in the specific diagnostic groups did not allow us to study the
putative association of different psychiatric disorders with the adoptees’ TDI level (II,
III). One further problem in our stability studies (II, III) is the fact that thought disorder
was evaluated twice. We have no way of knowing what had happened in the subjects’ life
during the follow-up time, and how the possible life events could affect the person’s
thought disorders. Furthermore, it was not possible to study reliably enough the
environmental factors in study IV. It would be especially important to know the adoptees’
place of residence during the follow-up, in order to study in more detail the high-risk
(HR) adoptees’ sensitivity to their environment (IV). The information concerning the
presence or absence of communication deviance in the environment would also be very
important. Unfortunately, the background data does not include information of the
adoptees’ place of residence. Thus, it is only possible to speculate whether or not it
affects the obtained results.
7 Conclusions
7.1 Main results
Early presence of thought disorder predicted a psychiatric disorder at follow-up (I). High
scores on TDI variables (TDR, 0.50 severity level, idiosyncratic verbalization) at the
initial assessment were found more often among the adoptees with ‘Any Psychiatric
Disorder’ (APD) at follow-up. This result was especially present among the adoptees
with ‘Any Other Psychiatric Disorder’ (AOPD). High scores at the 0.50 severity level
predicted mental disorders among the low-risk (LR) adoptees but not among the high-risk
(HR) adoptees.
The predictive value of thought disturbances is apparent, as thought disorder turned
out to be stable over time, especially in the most severe categories of thought disorder (II,
III). Stability of the TDI scores between the initial and follow-up assessments was seen at
the 0.50 and 0.75 severity levels, but not at the 0.25 severity level. Of Holzman’s
‘schizophrenia’ factors, only idiosyncratic verbalization was shown to remain stable
between the initial and follow-up assessments Again, it was shown that not only the
genotype affects thought processes. There was an association between the adoptee’s
thought disorder and the adoptive parents’ communication patterns in the longitudinal
perspective (IV). However, the adoptive parents’ CD predicted thought disorders at
follow-up only in the LR adoptees.
7.2 Clinical implications and implications for future research
Numerous studies have shown the presence of thought disorder in psychiatric disorders,
especially in schizophrenia. Furthermore, previous studies have indicated that thought
disorders occur most often during the acute phase of the illness and have both trait and
state features (depending on the context). However, our results provide further evidence
of the predictive value of thought disorder. Thought disorder could be one vulnerability
sign of mental disorder,and is thus an important factor in the recognition of psychiatric
disorders. Thus, it is essential to notice that other psychiatric disorders could actually be
54
recognized much earlier than we have believed. Furthermore, this study showed that
especially severe thought disorders are not transient states but clearly have stable
features. As it is stated in the current schizophrenia care guidelines,, cognitive deficits are
common in first-episode psychosis, and it is therefore important to use
neuropsychological assessment as one element of the whole assessment procedure, in
order to recognize the high-risk subjects as early as possible (Suomen Psykiatriyhdistys,
Käypä hoito, 2001). Thus, when a person has some specific psychic symptoms, the
evaluation of thought disorder should be one tool in this assessment process. In order to
accomplish a valid and reliable assessment of thought disorder, it is advisable to have
trained psychologists elicit the Thought Disorder Index (TDI) from the Rorschach test.
It is important to remember that the presence of thought disorder is not a definitive
precursor of later mental disorder. However, it is a critical sign that should be taken
seriously, and possible interventions to clarify the individual’s thought processes should
be designed. The connection between thought disorder and parental communication
deviance in adoptive families provides ideas of how to influence the subject’s thought
processes. If thought disorder occurs, it might be useful to give appropriate information
to him/her and his/her environment (including the family) about the connection of
thought disorder and psychiatric disorders and to instruct how, in practice, to clarify the
environmental communication patterns in a such way that it helps to structure the
person’s thought processes.
Future research is especially needed to clarify the environmental factors contributing
to thought processes. A further challenge is to investigate what kind of interventions
could be appropriately used to direct the person’s cognitive development, including
thinking, into the right direction. More studies are also needed to investigate the
prevalence of thought disorders in healthy populations.
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Appendix 1. The writing instructions for the Rorschach test
(these instructions are not complete)
A. Typing: The typing must be verbatim. The typist should neither “fix up” odd
statements nor distort through additions or omissions what a speaker has said. Reading
the scoring manual which follows, permits typists to see how raters willeventually
score the typescripts. The need for accurate transcribing of exact wording, word order
and reasoning becomes clear. Two main types of transcribing errors, either correcting
or distorting what a speaker actually said are to be avoided. These two problems are
discussed below.
1. Avoid fixing and correcting. Do not correct into better English, nor makeinto better
sense what is hearhd. Type without revising, substituting, or rearranging what is said
by speakers. Both beginning raters and typists should be familiar with the typing
remarks and descriptions which usually accompany viewing the Rorschach cards.
Speakers are often pointing to parts of the blots or describing features of the cards
which may be puzzling if one is not familiar with the typical exchanges which occur
during the procedure. Do not “fix” either normal ellipses, breaks in thought, nor
unusual phrasings such as illustrated below. Type what was actually said.
Here are a few examples of exact wordings, odd as they may be, which can
tempt a typist to edit, but which should be typed as heard.
I see ribs and of the esophagus.
These are protozoa, though alive they are.
A murial (sic) with outstretched arms. (i.e., mural.)
That is a carticaytchure (sic) of a man. (i.e., caricature)
To do with birth again I feel; they’re sort of uh, about to give birth itself
I think to one another.
2. Avoid distorting what is heard. If a typist faithfully avoid correcting what is heard,
only two other major problems occur; either the typing of sounds which some persons
append to words, or the failing to properly insert words which are said rapidly as a
speaker glides from one word of phrase to the next. The following examples illustrate
inclusion and omission errors:
a. Inclusion errors: Certain persons add an extra “uh” sound at the end of words
terminating in hard sounds such as “k”, “g”, “ing”, and similar sounds. These sounds
in ordinary conversation go unnoticed as part of the speaker’s regionalism or
idiosyncratic style, but are audible on tapes and are to be ignored. However, those
must be distinguished from those genuine separate “uh” sound which serve as space
fillers and non-word verbalizations, and which should be included in the typescript.
(a) Original incorrect typing of ”regionalism”: “That uh looks uh like a
dog uh with uh collar.”
(b) Correct version gained from listening to tape with knowledge about
the criteria above: “That looks like a dog, a dog with a collar”.
Inclusions such as in (a) above are not likely to be scored, but add to the work of
reading and evaluating a record. For global ratings such can mislead a reader into
thinking a speaker was extremely hesitant. The features below are likely to cause
incorrect scoring with the manual which follows this introduction.
66
b. Omissions: Failing to hear words of failing to indicate phrasing and pauses
can mislead raters.
(1) Word omissions: Short words are often elided as they are spoken.
They are formed, but faint and blended into the preceding word’s
ending or blended into the start of the following word. The
sentences below suggest a cryptic speaker:
(a) “Two figures bending forward touching something, tearing
apart”.
(b) “Here star which actually somewhat sevenpointed star”.
Rechecking the tape revealed the speaker had said many more words than a new
typist had transcribed. She had not heard the underlined words which were present in
elided form as shown here:
(a) “There are two figures bending forward touching
something and tearing it apart.”
(b) “Here’s a star, which is actually, it’s somewhat a seven-
pointed star.”
The speakers actually had fully formedand smoothly stated remarks.
(2) Phrasing omissions: A speaker groups his ideas in phrases and the
typescript should reflect accurately these groupings.
Example (a) below illustrates a failure to indicate phrasing.
Example (b) shows what checking and audiotape revealed.
(a) “Two large feet with a show with a high heel”
(b) “Two large feet with uh, shoes with a high heel”
Here a reader sees a speaker corrected his thoughts and phrased clearly whereas the
typing originally suggested one long peculiarly strung together utterance.
In summary, tapes must be checked, certain linguistic principles understood, and ideas
properly grouped until a faithful transcript of the tapes occurs.
Original publications
This thesis is based on the following original publications, which are referred to in the
text by the Roman numerals I-IV.
I Metsänen M, Wahlberg K-E, Saarento O, Tarvainen T, Miettunen J, Koistinen P,
Läksy K & Tienari P (2004) Early Presence of Thought Disorder as a Prospective
sign of Mental Disorder. Psych Res 125:193-203.
II Metsänen M, Wahlberg K-E, Saarento O, Hakko H, Tarvainen T, Koistinen P &
Tienari P (2005) Stability of Thougth Disorder Index among high-risk and low-risk
adoptees in Finnish adoptive family study of schizophrenia. Eur Psych 20:35-40.
III Metsänen M, Wahlberg K-E, Hakko H, Saarento O & Tienari P (2006) Thought
Disorder Index. A longitudinal study of severity levels and schizophrenia factors. J
Psych Res 40:258-266.
IV Metsänen M, Wahlberg K-E, Hakko H, Saarento O, Tarvainen T, Koistinen P, Tienari
P (2006) Longitudinal association between thought disorder of adoptees and
Communication Deviance of their adoptive parents. Manuscript.
The original papers have been reprinted with the permission from Elsevier (I-III).
Original publications are not included in the electronic version of the dissertation.
D908etukansi.fm Page 2 Wednesday, January 31, 2007 10:07 AM
ACTA UNIVERSITATIS OULUENSIS

SERIES D MEDICA
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U N I V E R S I T AT I S O U L U E N S I S
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A C TA U N I V E R S I TAT I S O U L U E N S I S
S E R I E S E D I T O R S
Miia Metsänen MEDICA
ASCIENTIAE RERUM NATURALIUM

THOUGHT DISORDER AS
Miia Metsänen
Professor Mikko Siponen
BHUMANIORA A PREDICTIVE SIGN OF

MENTAL DISORDER
Professor Harri Mantila
CTECHNICA
Professor Juha Kostamovaara
A STUDY OF HIGH-RISK AND LOW-RISK ADOPTEES
DMEDICA
IN THE FINNISH ADOPTIVE FAMILY STUDY OF
SCHIZOPHRENIA
ESCIENTIAE RERUM SOCIALIUM
Senior Assistant Timo Latomaa
FSCRIPTA ACADEMICA
Communications Officer Elna Stjerna
GOECONOMICA
Senior Lecturer Seppo Eriksson
EDITOR IN CHIEF
EDITORIAL SECRETARY
Publications Editor Kirsti Nurkkala FACULTY OF MEDICINE,
DEPARTMENT OF PSYCHIATRY,
UNIVERSITY OF OULU;
ISBN 978-951-42-8331-4 (Paperback) DEPARTMENT OF PSYCHIATRY,
ISBN 978-951-42-8332-1 (PDF) OULU UNIVERSITY HOSPITAL;
ISSN 0355-3221 (Print) CLINIC OF PSYCHIATRY,
ISSN 1796-2234 (Online) PÄIJÄT-HÄME CENTRAL HOSPITAL

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ASCIENTIAE RERUM NATURALIUM

BHUMANIORA A PREDICTIVE SIGN OF

Academic dissertation to be presented, with the assent of

ISBN 978-951-42-8331-4 (Paperback)

OULU UNIVERSITY PRESS

Keywords: adoption family study, communication deviance, schizophrenia, thought

Asiasanat: ajatushäiriö, skitsofrenia, adoptioperhetutkimus, kommunikaatiohäiriöt

2.1 General systems theory, biopsychosocial model

Comprehensive understanding of human development and the development of psychiatric

2.2 Thought disorder

2.2.1 Definition of thought disorder

2.2.2 Cognitive mechanisms in thought disorder

2.2.3 The qualitative aspects of thought disorder

2.2.4 Thought disorder in psychiatric disorders

2.2.5 Stability of thought disorder

2.2.6 Assessment of thought disorder

Thought disorder can be assessed by using interviews (structured or semi-structured) or

2.3 Communication deviance

2.3.1 Communication patterns in the development of thought processes

In general, cognitive development is attributed to both heritable (genetic) and early

2.3.2 The Definition of Communication Deviance

2.3.3 Parental Communication Deviance and the psychiatric

Parental communication patterns have been studied in psychiatric patients’ families.

2.3.4 Stability of Communication Deviance

2.3.5 Connection between parental Communication Deviance and the

The connection between parental CD and psychopathology in the offspring is obvious,

2.4 Summary of the literature reviewed

4.1 Study population of the Finnish Adoptive

4.2 Procedure of the study

4.3 Study samples in the original publications I-IV

4.4.1 Thought Disorder Index (I-IV)

0.25 (A) + 0.50 (B) + 0.75 (C) + 1.00 (D)

Table 1. b) Thought Disorder Index levels and categories (I Table 1).

4.4.2 The validity and reliability of TDI

4.4.3 Communication Deviance (IV)

Communication Deviance of both adoptive parents was assessed from tape-recorded

4.4.4 DSM-III-R diagnoses of the adoptees (I-IV)

4.5 Statistical methods

4.6 Ethical considerations

4.7 Personal involvement

5.1 Premorbid signs of thought disorder and psychiatric

5.2 Stability of thought disorder (II, III)

TDI score at follow-up assessment

TDI score at baseline TDI score at baseline

c) The 0.75 severity level of the TDI scale

TDI score at baseline

5.3 Association between parental Communication Deviance (CD)

6.1 Discussion of the results (I-IV)

6.1.1 Thought disorder as a prospective sign of mental disorder (I)

6.1.2 Stability of thought disorder (II, III)

6.1.3 Parental communication deviance and thought

6.2 Strengths and limitations of the studies (I-IV)

7.1 Main results

7.2 Clinical implications and implications for future research

ACTA UNIVERSITATIS OULUENSIS

892. Koskenkari, Juha (2006) Myocardial ischemia-reperfusion injury and systemic

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BHUMANIORA A PREDICTIVE SIGN OF

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